123 Applications & Permits No ? 6
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
oF
Appliratiun fur fli5pu5al Marko Cnnnztrurtinn ]grrmif
FEB 37-0 °
Application is hereby made for a Permit to Construct ( ) or Repair (t<an Indh idual Sewage Disposal
System at:
I. .3
acct
� asv
A'✓ 4
Installer
or Lot No.
Address
Address
S
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. IN 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. 1 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�p�PppP$icable.. alt",
Agreement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system In —
operation until a Certificate of Compliance has e en issued by th hoard of health.
SignneedA
Application Approved By
Application Disapproved for the following reasons• r
by
Permit No
Issued.
cx. /J.F.Q.._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Crrtifiratr of «tumplianrr
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.
DATE Inspector
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
hrrtifirate of (itnmpliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
Installer
at
has been installed in accordance with the provisions of TI LT 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.
DATE Inspector
No -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Disposal Works @ionntrurtinn lrrmit
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
FEE
at No - Street
as shown on the application for Disposal Works Construction Permit No
Dated
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FEE
Application fur Pinpnnul rancho Q iustrurtinn 1 rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (✓ ) an Individual Sewage Disposal
System at: —fite
r
Type of Building-
Dwelling--No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons
Septic Tank—Liquid capacity gallons
Disposal Trench— No. Width
Seepage Pit No Diameter
Other Distribution box ( ) Dosin
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
Test Pit No. 2 minutes per inch
ar Lot No.
Address
Address
Size Lot Sq. feet
Fxpansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
per person per day. Total daily flow melons'
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. f-.
gtank ( )
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Description of Soil_-
Nature of Repairs or Altera
us Answer when applicable
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bees issued by the board of hmlth.
Signed
Application Approved By i' '
it
Application Disapproved for the following reasons
Permit No '� Issued
Date
Da
THE COMMONWEALTH OF MASSACHUSETTS
.}- BOARD /OFHEALTH
Ctlti OF (7i FF
llrrtifirtttr of tIImplittorr
THIS IS TO� RTJFY. That the Individual Sewage Disposal System constructed ( ) or Repaired (PI
Iy �QQ k:mx
Installer
) X3.ord}Fr, ti,� 4?I.
as been installed in accordance with the provisions of Article pXI of The State Sanitary C de as de'scrAed in the
I
pplication for Disposal Works Construction Permit No F°'� dated ('/,,�'` 7.._%.7._T
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
iYSTEM W L FUNCTION SATISFACTORY. -i? . ' t eal
)ATF 24. X) fig
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
OF
itiopnsttltnrko„ffion;t trtion 3rrntif
Permission is hereby grant ca
o Construct; (
tNo (
Is shown on the
FEE
) or Rgpai?. . ),�ry_Indiv4 n ,,4ewage Disposal System
application for Disposal Works Construction Permit Ni f x Dated
Street '/
ORM 1255 HOBBS & WARREN
INC.. PUBLISHERS
7 (r
Board of I IPIth