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THE CONiMONWEALTH OF MASSACHUSETTS
BO�eRD OF HEALTH
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,���rlirtt�i�n fnx �i���a��t1 �.ark� Cn��,s�.rix.r�iun �[r�ntt�
Application is hereby made for a Permit ta Const:uct (✓) or Repair O an Individual Sewage Disposal
System at: ,
tYl Kl p- :7
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-__.. ony Address o Lot N / '
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J� Owner Addr,e�ss-�}��
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nstaller Address
dType of Building Size Lot_�,�J�j..�.�__._...Sq. feet
� Dwelling—No. of Bedrooms.__..._.__..Z__________________________Expansion Attic O Garbage Grinder O
p,, Other—Type of Building ____________________________ No. of persons__.._.____.__._._.._._..__._ Showers O — Cafeteria O
p`' Oth�r fixtures ---------------------------- -
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W Design Flow______!.�!d______________________________gallons per person per day. Total da�Iy flow..��1�__..__.�.....__.____......._gal�ons.
WSeptic Tank—I_iquid capacity�lJbO_._gallons �ength_�_.�_____ Width.��_l�__. Diameter________________ De th_,,��.�.__
x Disposal Trench—:Vo._.__../__...._____ Width_..f�_.__._.__. Total Length_..e�11___.______ Total leaching area___+_���...__._sq. ft.
� Seepage Pit No_____________________ Diameter___...._____..__..__ Depth below inlet__..._______________ Total leaching area____..__.....__...sq. ft. �
z Other Distribution box ( � Dosin tank ( ,� /
� Percolation Test t��� Performed b �t!??�t�/<<_�� .�'�71�___!��%���............. Date__1.:� ,��
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,..a Test Pit ;�1o�q________________minutes per inch Depth of �st Pit_.__.11_.____.__. �epth to ground w ter__.,Jt1______________.
(i, Test Pit No. 2________________minutes per inch Depth of Test Pit_.___..____.___..___ Depth to ground water_.___._.._______.____... ',
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� Description of Soil-•_---=�6_i�-_'"d�,y,__'�J_N_4.,��.t.�..._....•--- � �- - `----- - - - �'------------------------------
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V Nature of Repairs o: Alterations—Answer when applicable_______________________________________________________________________________________________
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the rovisions of�i'::.:� '
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' d b the�of health. '.
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Application APPr� - - � ---•`� ,1��-��......_..
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. Date
Application Disapprov or the f ollowing reasons---------------------------------------------------------------------------------------------------•------------
--•--------------------------•-------•--.............-------•----------------------------..._._._..---------------------------------------------------------------------------------------•------------
Date
PermitNo..---•------------------------------------------------_. Issued.-----•--..._...-------------..._..--------------------
Date !
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—— ——— . _ _. _ _____
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THE COMMONWEALTH OF MASSACHUSET7S '
BOARD OF HEALTH
..........................................OF...................................................................••••••••••-••••...
�rr�tfutt�e nf t1�um�littnr�e ''
THIS I E IFY, That the Individual Sewage Disposal S�stem constructed ,(x) or Repaired O ,
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���--/�%e�nstaller
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has been installed in accordance with the provisions of TI�'�Ly:� j of T e State Sanitary Cgd as d ' in the
application for Disposal Works Construction Permit No.__.._.p_._�_._`'�_________.. dated_.__l_,l�_ ___` ____ ________________
THE ISSUANCE OF THIS CERTIFiCATE SHALL PIOT BE CONSTRtlED AS A iJAR TEE THAT THE
SYSTEI�A WILL FUNCTION SATISFACTORY.
DAT�;-•-----•-------.....e------•.................................................... Inspector_..---•-------------------------•------••---------------•---._._.._.._._..._._...... �