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Fwcl.5. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARC7 HEALTH
OF .......... ........ -...........---- ----- .......
Appliration for 14spusal Works Cormnr ' n rumit
Application is hereby made for a Permit to Construct ( ) or Repair (an Individual Sewage Disposal
System at:
4%) "
Laty n Addr s� or Lot No.
Address
Installer Address
Type of Building
Dwelling —No. of Bedroo
Other —Type of Building
Other fixtures ..-,
Design Flow ............................ -----
Septic Tank —Liquid capa ty....
Disposal Trench — No ................
Seepage Pit No .................... Diar
Other Distribution box ( )
Percolation Test Results Jim
Test Pit No. 1...............
Test Pit No. 2 ....... .......
Description of Soil ......
Size Lot............................Sq. feet
......................................Expansion Attic ( ) Garbage Grinder ( )
.................... o. of persons..................--.--..... Showers ( ) — Cafeteria ( )
---•••-----------------•••---•--------.---•----------•--------------------•-----...----------------•------------------•-----..........
--gallons per person per day. Total daily flow ---- ......................................... gallons.
]ions ength................ Width ................ Diameter.-.-----.---.--. Depth ................
................... Total Length .................... Total leaching area .................... sq. it.
r-------- ---------- Depth below inlet.................... Total leaching area .................. sq. ft.
Dos g tank ( )
nedby --------------------------------------------------------------------•--- Date -------------------------------•-------
per inch Depth of Test Pit .................... Depth to ground water............----.....--.
per inch Depth of Test Pit .................... Depth to ground water..--.-----..............
------------------------------------------------------------------------------------------------------------ ------------- ------------•--....... ---------.....
Nature of Repairs or Alterations — Answer when applicable./�esy...�o_ r--- -
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system 'n
operation until a Certificate of Compliance has been issued by the boar of health.
Signed--- =........................... --�-----------------------
Application Approved By ......................... ................. ...................................... ---•.. __r
---------•-
ate
Application Disapproved for the following reason :-••------•-•--•---•-------••-----------------------•----._....---------•----------•--------•---............--
-----------------•---------•---•--------...---.....----•----•-----------------------------------.......................................................
..............................
•7 r_. Date
Permit No.- Issued 15 --- ------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD.1017 HEAL
C t . / f ...... s-�%...
fit
Ounrtifiratr laf f�nnt rli nr�e
THIS IS TO CERTIFY hat the Individual Sewage Disposal System constructed ( ) or Repaired C
-by----•./
----. � � C Ci nsItaller
has been installed in accordance with the provisions of TITIE 5 0 jState Sanitary C�. mc d a.,,,ss ibed in the
application for Disposal Works Construction Permit No.__, -- _.... dated---- -----
....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS UA NTEE THAT THE
SYSTEM ALL FUNCTION SATISFACTORY.
-
DATE ...... ......................................... Inspector...