App-Permit-ComplianceNo. �r.:::7..f� F$s:.-..��o
THE COMMONWEALTH OF MASSACHUSETTS
BQARD F HEALTH
Appliration for Mop sal irks Tonstrurtion Itermit
Application is hereby made for a Permit to Construct ( ) or Repair V -d an Individual Sewage Disposal
System at • _
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_._� ... Loc do - Add i or Lot No. __.________ .. ..........................
.............. ..-- --_---_-
(�^)/��f� /C/n-f�_ ddreaa�
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Installer 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 ........................
------------------ ---------------------•------------
Ali
Description of Soil... _..-....---
......-•--------------------------------------------------••.... •••..•--- ---
N tore of,,Re or Alt ation —
Xwen hp livable-// c-- - -.--- .-/ -...1 .. _"-.:��._..._--
.._.. r `t�-..._.....&.............•......--------............------.......-----.-----------------..................
_-A eement:The u ersigned agrees to ins 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 in
operation until a Certificate of Compliance has been issued by the board of h
Application Approved By..:...............1.
Application Disapproved for the following reasons:..........
-:................. ...-/ .�X
Date
........�� Date ' — .F
------------------------------------------------ --------------- I.......................................................................................
Date
Permit No..l..-`''�---........... ....._ Issued _......... ,.-..:1, .��:...t .._......
...
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tertif irate of Toutplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by--------------------------------------------------------------- ---------------------------- -- ---•--•--•------------------•----------------....------•---•-------.-----•-----------------•--
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 ....................................................................................