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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for Disposal Tons#.rixr#ion Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
.» .... tion -Address.. ` ........... _.. ... t No. ........................« ...«....
Ad
.. ..... ..........---......-----------................ ..I.- -------.
Installer Address
of Building I Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms... . . L., -...Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons ........ x..15.............. Showers ( ) — Cafeteria ( )
Otherfixtures ...............................................................................................................................•------------.....-----
Design Flow _........ �_l..Q.........................gallons per person per ay. Total flow. ____...-3-3,62 _.....�......gallons.
Septic Tank —Liquid* capacity-/QQOgallons Lengtl�..s.A dth_ -1.00 ameter D th................
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 .......................................................................... 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 ........................
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Nature of Repairs or Alterations — Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 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 boardj
th.
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Application Approved By. - -- /
ate
Application Disapproved foYlhe flouring reasons:
Permit No..----�?�_Y------------------ «.«.
VelEOS /-5'DUtL-j BOARD OF HEALTH
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Tntifutttr of Tomptittnrr
TO CERTIFY, That the Individual Sewage Disposal System constructed
THE COMMONWEALTH OF MASSACHUSETTS
has been installed in accordance with the provisions of TIT�F o The State Sanitary
application for Disposal Works Construction Permit No.-- -------- ------------------ dated—
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A
SYSTEM VIJLL -FUNCTION SATISFACTORY.
Date
) or Repaired (
THAT THE