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THE COMMONWEALTH OF MASSACHUSETTS
; BOARD OF HEALTH
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' Application is hereby ma.de for a Permit to Construct (�j or Repair ( ) an Individual Sewage Disposal
� System at: �E��Jd'
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� Address
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� Installer Address
! ¢ Type of Building Size Lot__�._�� Sq. feet
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i � Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'; a Other—Type of Building ____________________________ No. of persons......____......____....._.. Showers O — Cafeteria. O
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Other fixtures -----•---------•----•--••..................................•--...---•-----.._..--------------•----•---••-------------...._...---•-------•-------------
jW Design Flow.........._Y`�..-�?..........................gallons per person per day. Total daily flow_._____.._..�.�o..____.....____....._gallons.
� WSeptic Tank—I.iquid ca.pacity./�ao_gallons Length._.��G��.. Width.:�.�t=..'�__ Diameter________________ Depth_.:S'�'r
x Disposal Trench—No..................... Width...._........_...... Total Length___...__.__...._._.. Total leaching area........_.___...__..sq. ft.
� � Seepage Pit No._._._/_......____. Diameter.__...lv.�..... Depth below inlet.._.._�..�....... Total leaching area..�7_....sq. ft.
1 z Other Distribution box O Dosing tank O
� � Percolation Test Results Performed by...__�L"�J.!!�1.�9:!?:�...�.:..��.�............. Date__�-A:?�._ZL.��.l�.�.
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� ,..a Test Pit No. 1._�__:�.___minutes per inch Depth of Test Pit.__/s�..____. Depth to ground water_______________________.
fi, Test Pit No. 2________________niinutes per inch Depth of Test Pit._.____........_.... Depth to ground water____....._...___...._.._
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V Nature of Repairs or Alterations—Answer when applicable.__._._.........................................................................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI.E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
� operation until a Certificate of Compliance has been i sue the board of health.
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' Date
; APPlication Approved BY-•- --•----- �............. _.... ... ._..
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� .Date
' �PPlication Disapproved f or the f ollowing reasons:---•---••-----------------•------------•----•-------...........--•------...----•,-----••-• --•------..___...
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Date
� Permit No.------��..:ld,y � a? ��
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E THE COMMONWEALTH OF MASSACHUSETTS �
BOA�tD OF HEALTH �
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' THIS IS TO CERTIFY That the Individual Sewage Disposa.l S�stem constructed (�Yor Repaiz�ed O �
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has been installed in accordance itiv th the provisions of TITLF 5 of The Sta,te Sanitary Code as described in the
� application for DisPosal ��lorks Construction Fermit 1Vo.._��!..—%Q�............... dated___._...2_.i�:_� -.�y
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THE ISSUANCE OF THIS CERTIFICATE SHALL N07 BE CONSTRUED AS A GUARANTEE THAT THE
; SYSTEl�A WILL�FUNCTION TISFACTORY.
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