App-Permit-ComplianceN0;7..-_6
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® 9F HEALTH
......... OF ........ .... 9 ......................
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Appliration for Disposalark�orRepair
oustru.riion leruti#
Application is hereby made for a Permit to Construct ( ( ) an Individual Sewage Disposal
System at
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Loc Address or Lot No.
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Installer
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Address
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 ............... aL.? .P__________ --gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank — Liquid' capacity��.t, tOgallons 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 ................................................
............................................................................................................
Nature of Repairs or Alterations — Answer when applicable-__
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT 1E 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 health.
Signed-------------------------------------------------------------------------------------- ----------------------
Date
Date___ -
Application Approved BY ---------------6 ---- �-i_...... _. .
Health Officer Date
Application Disapproved for the following reasons-----------------------------•---------------------------------•----------------•---------------_------
..-•------•---...---•--------•-------•----------------- ------------------------•-------•--•--------•------------------..-----------------------------------------------------------•_----
Date
PermitNo ......................................................... Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ........... .........................................................................
Tntiftratr of Tontliftaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY•-••----------------•------------------•--------------------•--------•--------------•------nst ----
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