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THE COMMONWEALTH oFMASSACHUSETTS
BOARD,9F
-_-----'_ � �._'.-_-_
-_-_--'....................
Appliration for Disposal�
Application �
�
is hereby made �r u Permit to Construct( ) or Repair (�/ uo Individual Sewage Disposal
System at:
.... �fy. ..... ...... .... e ..............
dr
Installer ddress
Otherfixtures --------------------____________________________________________________
Dco' Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid* capacity............ gallons Length ................ Width ................ Diameter ................ Depth ................
Trench --Nu .................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No----------. Diameter .................... Doth below inlct---------- Total leaching area .--------'og. ft.
Other Distribution box ( ) Dosing tank( )
Percolation Test ]leanita Performed by .......................................................................... Date ........................................
Test Pit No. l ................ nniootc,yerioob Depth of Test Pit.---------' Depth toground water ........................
of
Agreement:
The undersigned agrees to install the aforedescribed Individual System inaccordance with
the provisions of TITIE 5 of the State Sanitary C kdehe ndersi 25er:es not to place the system in
operation until a Certificate of Compliance has been iss by e board 1
Date
by
ication Disapproved f5r the
Date
� THE COMMONWEALTH orMASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .---_-----'----.
Tntifiratr of
THIS IS TO the Individual Scvvugo Disposal System constructed ( ) or Repaired (�^)
/
has been installed in accordance with the provisions of TITJ-7 5 of The State SanitaV
,Xode as/descr�hed in the
application for Disposal Works Construction Permit No. --------_----- :::� ......... .. 7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A r -,u r, �ET_HAT THE
SYSTEM WILL N FACTORY.