711 Application & Permit 1969 No...�.:-....r....._.. FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
or
•r. Appliratiun for Disposal is arks Qlunstru�rtiun hermit
ris. Application is hereby made for a Permit to Construct ( ) or Repair Van Individual Sewage Disposal
System at:
µ. ..Location-.........._.....r'._L... ._ c.
.: r
. _...
Location Addrtss or Lot No.
•....... -..- ._.A.y
Owner Address
m Installer Address
U• Type of Building Size Lot Sq. feet
Dwelling-No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
d Other-Type of Building No. of persons Showers ( ) — Cafeteria ( )
G Other fixtures
W Design Flow gallons per person per day. Total daily flow gallons.
rL Septic Tank—Liquid capacity gallons Length Width Diameter Depth
xDisposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
z 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
w Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
O Description of Soil
M
U
UNature 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 - ._
Date
Application Approved By
AApplication Disapproved Date te
pp pproved (or the fo!louring rearons'
Date
Permit No • - Issued
Date
by
at
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF . .
oerrtifirate of Qtmtiplitture
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (!l
Installer
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 dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE - Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No r
FEE
Binomial r:i:urks Ojnnntrurtinu 1rrmit
Permission is hereby granted _
to Construct ( ) or Repair (/J an Individual Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No ...._._....__ Dated
DATE
FORM 1255 HOBBS & WARREN
a.era of Health