Misc. Septic Application 9 CHECK OR FILL IN WHERE APPLICABLE
No...kol.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ! 141
FEE./v U' if
Appliratinn fur flinpn,aal 3flnrks Cnnnstruninn ljermit
Application is hereby made for a Permit to Construct Qom ) or Repair ( ) an Individual Sewage Disposal
System at:
r.t¢.tet; i
cove.. Adp
wner e,
Installer
or Lot No.
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 ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capaci .OQgallons Length Width Diameter Depth
Disposal Trench—No. Width_ ` .4) Total Length 573 Total leaching area../4.O_r1_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:ITC 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.
Application Approved By
1
Date
Date
Application Disapproved for the following reasons'
by
Permit No li..:%.
Issued..
Date
7/077
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Tertifirate of Qdnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
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