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THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HE./ALTH
✓..... !�11/1�............ 0F....XW14&474! ;..----•...........................................
Allp iratiun for Dhipouttl Works Tonutrnrtion rnmit
Application is hereby made for a Permit to Construct
System at:
Loc ion - A r s
/_.i%c1�s�� ....P....W n .....................
Installer
Type of Building
Dwelling —No. of Bedrooms
Other —Type of Building ...
Other fixtures
) or Repair (�an Individual Sewage Disposal
Lo -r L 11 ►til a P I R)
........................•----•...---..... s ---------.... --••--...........
No. .� . .
.... .s
Address
Size Lot ............................ Sq. feet
........................Expansion Attic ( ) Garbage Grinder ( )
..... No. of persons ............................ Showers ( ) — Cafeteria ( )
-----.....-•---•...---------
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. 1................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 ........................
---------------------------------------------------------------------------------------------------•-•-•--..........
Descriptionof Soil ...............................................................................................................................
---------------------------•--------•-----------•--•---•-----------------••--•----- s - ----------`•- ---------------------
Na of Re irs or Alterations — Answer w1�en applicabl,. � ,;ll _c�_. �<� �_"-------- '......
------------------------------------------------------------------------•------------------------•-------
Agreement :
The undersigned agrees to install the afor,
the provisions of TITLE 5 of the State Sanitary
operation until a Certificate of Compliance has be
Application Approved By,
Application Disapproved for the following reasons:
Permit No ........ ---------------------
Sewage Disposal)§,ystem in accordance with
ned further rees not to place the system in
1.
Qate
-------------------.......... ..... Y_..
Date
--------------------------------------------------------------••---
Date
Issued ........ ............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEA
GlJst/ .......... OF ......
........................... .
Trrtifi.rat a of Tontulinrr
THjg/S„TO CER.TIF ; That �- Indi idual Sewage Disposal System constructed
G. ,v
by
�- - j
Installer
) or Repaired 4_<
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.. o ..:.. C�............................................... Inspector.......... ..�