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�� BOARD OF HEALTH
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� Appliatim is hereby made for a Pumit to Constcuct (� or Repair ( ) an Individual Sewa�e D�pop1
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� Dwdlin8—No. of Bedrooms•___._______•_•_-______-_Expansion Atdc O Cnrbage Grinder O
� Other—Type of Building ..._.._..._�.____ No. of persons._•_...---___.__.__ Showers O — c.ta� O
om«,t�s�,r • ••-•_--_......•-••_.._..___.._..__....._•••••---••••••••••........._.._.._. _...._......_._..
Design Flov....._..__.�?�� -------------.�(o� • �L o�.
� . •_•___._...-• per ,p,(�day. TotaLila�l 8ow...__...._�_.........._,�ttlS
SePtie Taak—Ia9nid caPacitY�...�allons I.ength�3S'..''_••• Width_���- . niameter......._..••• r�,.h `�'
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Dispoeal Tra�ch—No.•__....._•_•_. Width.�__......___.Total Lmgth-•__•_. Toql lmchiog arn.___..Y._.�q.h.
3 Scepage Pit Na.�,i��_ Diameter..._�---._....•• Depth bdow idet_3�..�_�_.._Total lesdiiog as�.l..�.�_..eq. ft.
� Other Distrlbution booc (� �B� �
� Percdation Tat Resnita Performed by. -. ���.... � U�P
.... .. .. ..._ �.__.+�...... . �........
Test Pit No. 1_•••..�.L.._•..minutes per inch Depth of Test Pit_.I�.�.`_ Depth to ground water...._�_•__..
Teet Pit Na 2..____••_..minntes per inch DeptL of Test Pit.._...___...... Depth to grwnd water....._____...__•
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Desviption af Soil__�.�..����—_._._�LL�?�.�N�_____.��.4�!!.1.5?���
� __..........____•-____-•___.._.�__......•-•__-._�_....�__......___••......_•________..._.•.._.._•__.._•_�.........-..�..__.�...._
.._.._..................................._..._.---..._._........-----...J....o..................._.......-----_....._...._.._._..r...._..
Nature af Repairs or Altaa q'ons when appl' ble.............. ...... _ •••• • -• ~ •••
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The undersigned agrces to install the aforedescribed Individual Sewage Dispoaal Syatpn ia aooadanoe with
the prm-isions of iITLE 5 of the State Sanitary Code—The nndersigned furthv agrees not to plate}lx syatem jo
, opvation unt�7 a CertiScate of Compliancc has bem ' b board of health. ,
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Applitstimt Disnpproved for !he follomviag tsas .••_............•____.»......___••__•_• ....._.......... ,�,_,,,,_
.........__•__....•_-_.....-_•_.....•___....._._..._._______..._......____...__•_______..___.._..__•_..__..__.._
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THF COMMONW6ALTH OP MA83ACNU86TT6 � �
BOARD OF HEALTH
G�rrtiff,ctt�e af �tum}�Ifi�nr�e �
THIS IS TO CBRTIPY, That the Ind'evidnal Sewage Disposai gystan constn�cted (vf or g�,�( � �
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at___.»..�...__._..•__•••._.._._....•_•••..L:._._•••••......._._. �_.._._••••••_--••-•_...._. ..._....____._._._........_.......::;.s.M.....: �
has been insqUed in accordaiue with the provisions of TITIE of,�he State Sanitary as desrn'bed in t6e
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appliradon for Disposai Works Constmction Permit No.��.'..._O t�.••••_•....... �ted...!�/..����....__..........
TIlE ISSUANCE OF THIS CERTIFICATE SHALL NOT!E CONSTRYEp Af A Qr11ARANTl�TMAT Tly I
SYSTEM WILL WNCTION SATISFACTORY.
DATE....._.....�..__...____....__......_..._..___.�._.� Inspecbor _. ", I