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THE COMMONWEALTH OF MASSACHUSETTS
BOARD H LTH
...._.....OF- ...:..._........................................................
App iratilan for BW sat Warks Cnnnstrnr#ion rnmit
Application is hereby made for a Permit to Construct ( ) or Repair ( L<an Individual Sewage Disposal
System at
oe
Edi �(� 3 M P °
.................. .. - .----•---•---------------..------•---------------?..-- .......---
r dress or t No.
..... ...... ..............
es
........................--
--- --------- ------ -- ---
Installe Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------.-----•--•-•--•-••-----•---••-•----•••••-•------•-----------•-----.....-----•----...........•---
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 ........................
Description of Soil --------------------------------------------------------------------
.---------------------------------------------------------------------------------------------------------------------------------- ---••----•..........................................................
-----•---•••-•--••-----------•------••••---•----•-----••-•----•••-•-••-•-•-•••......-••---•-•---••------••••• -- ----------------------------------------------
---------------- -
ature of Repairs or Alterations —Answer when applicable ... __________________ S .__._____ �:�.�>.�..........._..
NC. ._..._�.�-0.........::......
Agreement:
The undersigned agrees to install the aforedescribed I ideal Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — e dersigned fu ther agrees not to place the system in
operation until a Certificate of Compliance has be n iss d b o of
ned....... •-•--• •-- -- ........•---- --- - --- ---..........--.•-•--- ---
Application Approved BY - • -• •-----......-••---.......
�1e..
/Date
Application Disapproved for the following reasons-------------•--------------•--------------------------•---•---------------•---••--- .........................
..................•••----.....-•------------•--••--•-•-•----...............--------------...-•--•--------•--------------------•------•-----•---•----••-•-. ------------
-------•---------------
�- Date
Permit No ---------- � S C Issued ------•d
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAD,H
.......................................... OF ... ... ...........................................................................
Tntif #r of Tomptiaurr
T I TO E IIT t t ndividual Sewage Disposal System constructed ( ) or Repaired (!.
by....:... r•-e!/Gs ��/�
........... ....-_._------.. _l....---_......------------..._................-----------------------------
alle
at G --- �G
has been installed in accordance with the provisi of TITIN 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 ....................................................................................