76 Applicatios & Permits ERE APPLICABLE
IECK OR FILL IN
No 0 9
Fax_�._t.
THE COMMONWEALTH OF MASSACHUSETTS
_ytA. OFDO HEALTH
Applirutinu fd'r finpn.ittl Marks Tatmtrurtion Permit
Application is hereby made for a Permit to Construct (
System at:
M , 69,<
tkri ddre
24 .h1. - Address
) or Repair (P en Indic ideal Sewage Disposal
or Loo No.
tnstoner
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other Rctures
Design Flow gallons
Septic Tank—Liquid capacity g'dlons
Disposal Trench--No. Width
Seepage Pit No Diameter
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
ndmes.
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No of peso, Showers ( ) -- Cafeteria ( )
Other Distribution hox (
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
per person per day. Total daily flow allons.
Length Width_ —_ .._ . Diameter__. Depth
Total Length Total leaching area sq. ti.
Depth below inlet Total leaching are vt_ L.
Description of Soil
Nature of Repairs or Alteratirss—Answer when applicable
/2Qa yet, itAeze
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee• ssued by the board of health.
°. ]f 7s
Application Approved By
Sign
Application Disapproved for the following reasons'
Permit Na.. t7
Date
//T,
Issued. (at ../yin
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Ctrrfifirafr of Tnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Inswn«
at
has been installed in accordance with the provisions of :Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No elated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF �
Jioonia1 Marko innnmfrnrtinn ihsrmii
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No
FEE.
Sea!
as shown on the application for Disposal Works Construction Permit No Dated
Board of HgIth
DATE
FORM 1255 HOSES & WARREN. INC.. PUBLISHERS
%on
ERE APPLICABLE
CHECK OR FILL IN
No 61 gel"
THE COMMONWEALTH OF MASSACHUSETTS
Applirutinn-faQ 3i5po5a1 Rinks Cnuuutrurti u lJrrutit
BOARD OF EALTH
OF I.
FEE __Co 8
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Ltdir ideal Sewage Disposal
System
at
Lint V u.*e^.."W t ees aAddrc co.
Acid)ers
Size Lot Sq. feet
Fxpansion Attic ( ) Garbage Grinder ( )
of persons Showers ( ) — Cafeteria ( )
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Bufldi ng No
Other fixture
Design Flow gallons
Septic 'hulk—Liquid capacity gallons
Disposal Trench No Width
Seepage Pit No Diameter
Other Distribution box (
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil.
per person per day. Total daily flow gallons.
Length Width Cr Uiamet Depd' -
Total Length "Total leaching area el. ft.
Depth below inlet Total leaching :ire- sq- ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test 1 it Depth to ground water
Nature of Repairs or Alterations—Answer when applicable / -- -
Agreement: .
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code— The undersig: d further agrees not to place the system in
operation until a Certificate of Compliance has bee issued hepoard healt .
Signed _ I/ a_._.
Application Approved By
Application Disapproved for the following reasons'
1t!/17 —
Permit No._CFI, Issued
D
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Gtrrtifirafe of faumplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
InstalIer
at
has been installed in accordance with the provisions of Article NI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Jis}mna1 Rink; cfamatrurtiutt tIrratit
Permission is hereby granted
to Construct ( ) or Repair ( ' ) an Individual Sewage Disposal System
at No
sum
as shown on the application for Disposal Works Construction Permit No Dated
Bmrd of Health
DATE
FORM 1255 HOBS B WARR EN. INC.. PUBLISHERS