82 Application & Permit 1979 CHECK OR FILL IN WHERE APPLICABLE
No '-1 -i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF 7 ;.,.ly' x.frfj1 :
Application far £lispnsal Illorka (nnatrurtian hermit
or Repair ( an Individual Sewage Disposal
Application is hereby made for a Permit to Construct
System at: y '
Locatbn,.Addreu
instaucrt
or Lot No.
Address
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench —No Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable.,,,e415.f.//e f -f. f L....;:.. -0 ([$!t_.
t
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of:In.: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has sued» tJt yard of health.
Agreement: V
Application Approved By
Signed_
Date
Application Disapproved for the following reasons'
Date
Permit No....
�� Issued , V 1, { . —.
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.
Qlrriifia&r of Tamplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of TITLE 5 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.
DATF inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF {{HEALTH
l .f OF i I...TTA,,. . —
FEE
Tinpaunl Worko Otnnointrttnn tirrutit
Permission is hereby granted „„..7
f"` `
to Construct ( or 1-epair (° ) an Individual Sewage Disposal $}istem
at No �'...,:j.`.=r:.�..:,._i : I/,
Bret
as shown on application for Disposal Works Construction Permit,Na
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Dated._ !x
Board of Health