Misc. Septic Application 11 CFIECK OR FILL IN WHERE APPLICABLE
No. �J---- FEE.,/. ,.✓
THE COMMONWEALTH OF MASSACHUSETTS
jBOARD OF HEALTH
1) ppliratinn fil'r i3inpnnai lflnrk5 (Qnn ilrurtiutt hermit
Application is hereby made for a Permit to Construct
System at:
6) I Loe ,Add:o
s
In
Type of Building
Dwelling— No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow •
Septic Tank—Liquid capacit d gallons
Disposal Trench—No. Width
Seepage Pit No Diameter
or Repair ( ) an Individual Sewage Disposal
or Lot No.
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
gallons
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
per person per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching areal W sq. ft
Depth below inlet Total leaching area sq. ft
Dosing tank ( )
Performed by Date
minutes per inch Depth of "hest Pit Depth to ground water
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 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 health.
Signed Q'p'2�' Ai. ti'rL�a ....._________________
Application Approved By
Application Disapproved for the following reasons-
cfmaident
I-/-9E6
Date
by
Permit No 3..Il 2 Issued
Dat
/ 9. d_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Ciertifirate of Cinmplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
Instaner
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