5 Application & Permit 1966 No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FEE
1 ppliratintf far 3ispus zt cc arks oinuntrurtinu tirrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location•Addres
Installer
- r Lot No.
Type of Building
Dwelling— No. of Bedrooms
Other—Type of Building No
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No Width Total Length
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank (
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
- Test Pit No. 2 minutes per inch
(A #...4-4--
."address
O Address
'�Size Lot Sq. feet
i
Expansion Attic ( ) Garbage Grinder ( )
of persons Showers ( ) — Cafeteria ( )
gallons per person per day. Total/daily How_ gallons.
gallons Length Width Diametei Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
Description of Soil
)
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual wage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersign d further agrees not to place the system in
operation until a Certificate of Compliance has be�r issued by thA brrd of health.
) (1 V49Ji
Signed../ � j
Application Approved By
Application Disapproved for the following reasons
Permit No
Issued
Da
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
.7`
Tittifirtite af affitttpliann
THIS IS TETC,ERTIFY, Tharty,Individua/ Sewage Disposa/ System constructed ( ) or Repaired ( )
by................................... . .......,....................... ....... .. .. ..... ........ ..... ................. .... ...
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--------------------------------------- dated . .. .. . .. ........................
SYSTEM WILL FUNCTION SATISFACTORY.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
D ATE
; -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r/
No '/_.... . - OF . .. .A. . . . .n. .. .
.. . . .
Bigiutattl mita (Intistrudiutt Prtntit FEE.......................
Permission is hereby granted A--Zro
at No
to Construct or Repair (1.--- individt, Swage Disposal System
. .. ...............
as shown on the application for Disposal Works Cohstruction Permit No. 17 Dated /./. - .......
Street . ....... ..... .. . .. .... ...............
r —
->
DATE-------- (. . . . . .. .. .. ... . .................... Rood of RANO
FORM 1255 HOBBS & WARRENNC.. PUBLISHERS