4 Application & Permit 1982 No ?3—g
THE COMMONWEALTH OF MASSACHUSETTS
cOARD Iy'y^F H ALTH
OF ' l.
Appliratinu far iiiispanat 'Marks QTnnstrixrtinn 'hermit
FHH_lit Y.�......
Application is hereby made for a Permit to Construct ( ) or Repair (14n Individual Sewage Disposal
System at:
or Lot No.
Addre
Addrea.
Type of 1uilding 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_ Repairs o; Alter tions—Answer when applicable Clef_—JZ_ 2.
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to
operation until a Certificate of Complianc been issu-d by the board . health.
Application Approved By
Sign
in accordance with
place the system in
Application Disapproved for the following reasons:
Permit No '33 r)--
Issued
THE COMMONWEALTH OF MASSACHUSETTS
Let 0;7)1
liCrrliWatr-vf afmnpliatur
THIS IS TO CERTIFyi, That the 'rift:v./dual Sewage Disposal System constructed ( ) or Repaired (t---)
BOARD OF HEALTH
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 2
No
(
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Eigpanal
orkg Tun:grunion frnitit
Permission is hereby granted
to Construct ( ) or Re7:„ an Individual wage Disposal System
z'
at No
A'
FEE
C-1
as shown on the application for Disposal Works Construction Permitlir':% ,Dated
, , ,
DATE - Board of Health
FORM 1255 A. M. SULKIN, INC.. BOSTON