15 Applications & Permits THE COMMONWEALTH OF MASSACHUSETTS
RD DF li£ALT
Application fm' Bispnssl Works (Construction Frrmif
Application is hereby made for a Permit to Construct ( ) or Repair (A') an Individual Sewage Disposal
iyetem at: ``,
Type of Building
Dwelling—No. of Bedrooms { / Expansion Attic ( ) Garbage Grinder (X)
Other—Type of Building / No. of persons Showers ( ) — Cafeteria ( )
Other fixtures _ _...—......
7esign 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.
Total leaching arm..._......._.._sq. ft
'el
Installer
or Lot No.
Address
seepage Pit No Diameter Depth below inlet
Jther Distribution box ( ) Dosing tank ( E a F
Percolation Test Results Performed by l..._
Test Pit No. 1 �)•"'minutes per inch Depth of t Pit...7
Test Pit No. 2 .minutes per inch Depth of Test Pit
Dace.._ 30 7/j
N Depth to ground water
Depth to ground water
Description of Soil
Natur oLR or Al lions—Answfj�w apalita
Stre
Agr ent:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the p ovisions 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 issued by th board o health.
Application Approved By
Application Disapproved for the following reasons•
at
has been installed in accordance with the provisions of TITLE 5 of a State Sanitary Codelas d 'bed in the
application for Disposal Works Construction Permit No ./o ---ir l dated if
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GU- _ =-[THAT THE
tr._
Permit No
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF I-1 LTH
ifirxfr of Qtmnp anrt
THIS TO I Y t dividual Sewage Disposal System constructed ( ) or Repaired (4
Installer
Date
y
THIS TO
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H LTH
OF..
er/tifirttfe of Tomtit nu
hat tpe Zpdividual Sewage Disposal System constructed ( ) or Repaired (>9
Installer
L
as been installed in accordance with the provisions of TITLE 5 oil he State Sanitary Code as described in the
pplication for Disposal Works Construction Permit No EB ' dated yr/.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GUARAA TEE.THAT THE
;YSTEM WILL WNC (QN SATISFACTORY.
/ Inspector
r
)ATE h Inspector
Permission
o Construct (
a No
is shown on the
DATE
'ORm 1255 A
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
flispnnat
onto fttnnstructinn Permit
is hereby granted
) or Repair ( ' ) an Individual Sewage Disposal System
FEE
.. Street
application for Disposal Works Construction Permit No Dated
SULKIN. INC., BOSTON
Board of Health
Fax
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for Binomial ,r nrks (Itnnstruction 'hermit
Application is hereby made for a Permit to Construct ( ) or Repair (: ) an Individual Sewage Disposal
System at:
Location.Address or Lot No.
Owner
Address
Installer Address
Cype 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.
Dther 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
Agreement:
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 been issued by the board of health.
Signed .....__.-➢u5
Application Approved By
Date
Application Disapproved for the following reasons•
Data
Permit No Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(llnrtifiratr of f nmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (V')
Installer
at
has teen 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 dated -z -'1 i..2 4 j....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE z Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No FEE
Permission
to Construct (
at No
Dismal Itlurka 011onstrnrtinn jrrmit
is hereby granted -
) or Repair ('-5 an Individual Sewage Disposal System
as shown on the
street
application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOSES & WARREN, INC.. PUBLISHERS