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Xplifiration
for Dhopmial�
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u"�;,°�"" khprehv made for u Permit to Construct (56 or Re -pair ( ) an Io6ividoal Sewage Disposal
Address m
Address
Dwelling —No. of Bcdr000�u----'�`.'---'----------' inn Attic( ) Garbage Grinder( )
I� of 8b ( ) Cafeteria
Other—Type of I}o�d�q� --_-------_-- o. persons Showers -- `
Other___.______________________________________________________
Deoign Ilmw-- per p�souper day. Iot�da�yflow c--'-----------------'J�ko�.
SepticTuok-L�o� Length ------_' Width ................ Diameter ................ Depth -------
D'mdTreocb-No.----------Widt6-----'---'Iotal Leogtb---------'Iotal leaching area --------'_- sq. ft.
Seepage Pit No --------------------- Diameter .................... I}cot6 below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Datc------------------..
Test Pit No. l ................ minutes per inch Z)eytb of Test I'iL...------'- Depth to ground water ........................
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u Description of
-------------'--------`-------------------------------- *
-'------------'-'------'--'-'---------'--'--'------'----'---'-----------''---'-----------
~� Nature of Repairs orAltcradooa--z\ouwcrwbeo applicable ---.--_-_-.-------..-------.--.._---_-__-____-
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Agreement:
The undersigned agrees to install the uforc6coccibed Individual Sewage Disposal System io accordance with
the provisionsof7ITA IE 5 of the State Sanitary Code — The undersigned further agrees not toplace the system in
operation until a Certificate of Compliance has been issued 6ythe board ofhealth.
Signed- ______________________ ________________
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Application'' -_ . Date
Application Disapproved for the following reasons: ................................................................................................................
.................................................................................................................................................................... ---------------
Date
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Permit No Issued ..........................
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Date
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THE oowMomvvcALrH OF mxseACoussrrs
OARD OF LTH
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THIS JSJ�T)00 CERTIF SLI
constructed><) or Repaired
V), Installer
has been installed in accordance with the provisions of T1 of ate Sa ita'ry Code as described in the
da
application for Disposal Works Construction Permit No.. dated -----------------------
THE ISSUANCE OF THUS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
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