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THE COMMONWEALTH orMASSACHUSETTS
" BOARD OF HE �JH
�"0
Appliration for Disposal
is hereby made for a Permit
Installer
e7 0
Construct or Repair ( Pj"an Indi'Idual Sewage Disposal
�
or Lot N
res
Address
Type of Building Size
—
Dwelling of ageer'
Other --Type of Building ---'_----'----' No. c6persons ............................ Showers ( \ -- Cafeteria
Otherfixtures ..........................................................
Design Flow ........................................... gallons per person per day. Total daily flow ............................................
Septic Tank L�o�l Leoe��-----'--' D�o�ete�-----_..Depth -'-----_
Disposal Trench --Nu.................... vviutu-_-------'zotal Length .................... Total leaching area ----'_-'---ug ft.
Seepage Pit No ..................... Diametec--.------- Depth below inlet .................... Total leaching mreu-----'---ml. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .--_.----_-------------------'----'..-' Date .........................................
Test Pit No. l ................ mioutcxpecioch I)optb of Test Pit .... Depth toground water --_.------_.
---------
f ReDairv,or
.
Agreement:
The undersigned agrees to install the aforedescribed
the provisions ofTLITA LE 5 o the State Sanitary Code
operation until u Certificate of Compliance has beep iaaie�
Application Approved By_�o_t
Application Disapproved for the rooxons:............................^^ -^~
Disposal System in accordance with
A.ercs eno o place the system in
Date
Date
_______
Date
Date
________________________________________________________________-
rmsoowMomvvs^Lr*orxvAssACeossTTS
BOARD OF HEALTH
---'��F'-- _________._____
Tntifiratr of Tamsdiatta
^
T W 1S,,,T0,CERTjfl,Y, Tlr4,, the ln�di lial ��evage Disposal System constructed( )or Repaired (J.,�
has been installed inaccordance with the provisioiis ofgITLPE Code as described in the