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THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0 HEALTH
n/..............OF............ < .�. M(1-v_T/'/.........................................
, ppliration for Disposal Works Tonstrurtion 1rrmi#
Application is hereby made for a Permit to Construct ( ) or Repair k) an Individual Sewage Disposal
Sy_ at .. .....1.`.... ...... .��.................................. ........ - ------...........
GCT = T� 0 2.-
-Location-A es 1��..t l/..... ... _...... •f C- �••.... ��fl -� L... -or Ut No...�C! �--------------
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Installer • -•• • Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) .Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures.....•-------•---•-•-•..........................•-••--•••••---•••-•-•-----••••-------•--._........_._.....-••••-•••••••._---_____________._.....:_._..
Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity�&Q:P___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 W) Dosing 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 ........................
Descriptionof Soil................•----------•------.....---------------...-----......._.......-----------------------.._...---------•---......------------------.........--•---•---••----
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Nature of Repairs or Alterations — Answer when applicable ........... '2------- .......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 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 b the board of he,�lth.
Signed.1.
- -- -----••----•-•----•---------••- ------ -- ...1`----- _ - � S ---
ApplicationApproved BY ...................................... --••---..._..-•----•----••-------•-- ••-----.y-
Date
Application Disapproved for the following reasons:
Permit No ... 8_� �K. .....................«....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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. ..1 .4...... V..............OF......... ......................................
Ta ifiratf of (911M. knurl
THIS IS ,TO CERTIFY, That the Individual Sewage Disposal S7stem constructed
Date
or Repaired O
r Installer
has been installed in accordance with the provisions of TITLE 5 of The State .................
Sanitary o as described in the
application for Disposal Works Construction Permit No._ �r _,t `� ........... dated_.. t'��.I_.c�a_� ..:
PP Dis p 1 ,t-.---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
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DATE .... Inspector Y �i?'..� .i4iL ... '� s _ ..--- ---
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