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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �V
71 .............. OF ....... r!.�� �..`..._......................._......_....................
.............................
Appliratiun for Disposalorks Tonsirudion Fermi#
Application is hereby made for a Permit to Construct () or Repair ( ) an Individual Sewage Disposal
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Locaj......... Address o t No.
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1--1 Installer Address
Type of Building Size Lot -1.91. � l d _Sq. feet
Dwelling —No. of Bedrooms............ ��.....................Expansion Attic ( ) Garbage Grinder .FVa )
Other —Type of Building No. of persons ............................ Showers — Cafeteria
Other fixtures ...................................
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Wx Design Flow. --------..-If ...------ .gallons per 8 -Z _Z
. .. ...............
Total 0A..........._glow.
Septic Tank — Li uid'ca acit �gallons Len------------ -. Width ........ Diameter --- ��5.)`.....
Disposal Trench — No. ..........f ........ Width ------ I_�------- Total Length ......D...... Total leachingarea-•-......._..sq.
ft.
Seepage Pit No --------------------->ameter.................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box (✓� Dosing tank ( ) �t- TO�� l� 8� 8/cOgg
Percolation Test Results Performed by.f �^'r�`'Z.---- ••--••••••----•----------- Date..__..i.................
,''la Test Pit No.,3 ••-� Z _...minutes per inch Depth of Test Pit... �` `� F.... Depth to ground water...-/ �z.� �...-__.:
Test Pit No. I .... 4..' -..minutes per inch Depth of Test Pit --- 1_, 2 _...__. Depth to ground water.... .........
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Description of Soil..... ..............................
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Nature of Repairs or Alterations — Answer when applicable_----•---------------
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agree
operation until a Certificate of Compliance issue+Vy he� f health.
Application Approved By -.--•----------_---.VL
Application Disapproved for the following
System in accordance with
s ntt to place the system in
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Date
.-.------•-----------------------------------
Q � Date
Permit No... S9. -- ---------------------- Issued- ........ f�._¢ hl L...----- ...........
Date
4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ..........................................................
Trr#ifirtttr of Toutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
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Installer
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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.
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