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THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
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Apphration for Disprrjaal Workonstrurffott thrutit
Application is hereby made for a Permit to Construct (-V/) or Repair ( ) an Individual Sewage Disposal
I� System. .... C . l __
--ocatioxi - dd ss •------- -
/�_or Lot No.
1
.._....
Owner ....................
W Address
M Installer
6A -------------------
._.......-•-----------------•---.......--
Type of Building
Address
Size Lot____________________ __ ___Sq, feet
Dwelling —No. of Bedrooms ............................................ Expansion Attic
( ) Garbage Grinder ( )
Other — Type of Building __________________________ _ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow ...... f/49 .... _........... ............ gallons per person per day. Total daily :�flow ----- __. _��_��_ ------------------------ gallons.
Septic Tank — Liquidcapacity,�j07sgallons 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 ( ) Dosing tank ( )
Percolation Test Results Performed by_________ _ _ ___
Test Pit No- 1________________minutes per inch Depth of Test Pit____________________
Date____.__..___..__..._.._______.___...___.
Depth to ground water
Test Pit No. 2 ................ minutes per inch Depth of Test Pit ....................
............... _.______.
Depth to ground water ........................
..---•--•---•-•-•----•---------- -----------------------•--•--•------------•--------_----
Description of Soil.
------------------------------------------------
Nature of Repairs or Alterations — Answer when applicable.
Agreement:
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The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT-.%, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee su the board of health.
Signe
r••------•----- --
Application Approved By---•-----•--------••----------..................................ate
Application Disapproved for the following reasons: .........
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PermitNo ......................................................... Issued_ ........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
.............;1�,1.. `.... oF...........rf....................................................
Trrtifirate if (1 outpliaurr
Date
Date
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (,\-,)-'or Repaired ( )
by........ �•�... :... , .......... r ,-v`r�: ------------------------------------------------------------------------
/ �+ Installer
=--------------------•---------------•----------------------__ -----•------------_________------------
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.___f______ _ __ ............. dated __r..��1, "...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BION TRU AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ................... Z------- ��.G-... :2.,k ---------------- Inspector �----•--------------.,..-�-----•-�--