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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratilaru for Disposal Warks Toustrurtinu 11nutit
Application is hereby made for a Permit to Construct
System at-,
F'� Location - Address
�.............................. I.J.-B ..........
Owner
................. Wt i.. --------.w �!^► s ....................................
Installer
Type of Building
Dwelling — No
Other — Type
Other
Design Flow .............
) or Repair ( ) an Individual Sewage Disposal
--•-•-....... .. T " J7 /Y. pP...3------------------------------
or Lot No.
. of Bedrooms ----------------- ______--------------------- Expansion Attic
of Building ---------------------------- No. of persons ....................
fi xtn res
Address
----------------
Address
Size Lot ------------------- --------Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
--------------------- gallons per person per day. Total daily flow........ _................................... gallons.
Septic Tank — Liquid capacity .... .------- gallons Length ................ Width ._...__..__..._. Diameter ................ Depth ................
Disposal Trench — No- -------------------- Width ................. Total Length-------------------- Total leaching area -------------------- sq. ft.
Seepage Pit No ..................... Diameter -------------------- Depth below inlet -------------------- Total leaching area .................. sq. ft.
Other Distribution box ( ) D
osing 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 Uab.... -r .S1/<.. w
-o--e --------------------------------------
..-----•------------------------•-----••---••---•--•••---- ------------------------------------------------------ -- ,7
--------------------- --------------------- --------
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Nature of Repairs or Alterations — Answer when applicable________________
greement
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 is ued by the board of health.
Signe ..__aZ/– F 3
Application Approved By .................. -- Date
Application Disapproved for the fol owing reasons: ............................. Date
----•------------------•------------•-----............................................................
Date
Permit No..•-• ` 3. �,............................Issued._.. _2......
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Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Air
wrtifiratr u f��aut �iuttrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
J�� Installer
---------.....................................
--•--•--- ...........................•-----••--•-------------••-••-----•----------...---•-----------•--.
has been installed in accordance with the provisions of TIT F. `> 9f'T State Sanitary Code s decrib d.in the
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application for Disposal Works Construction Permit No________ ________________________________ dated ------
._.-......._ __..__.__...___.__.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT NSTRUED ASA GUARANTE AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE $:/.2 �•---•---•-•---------------•---....•. InsP�