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THE COMMONWEALTH OF MASSACHUSETTS
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BOARD OF HEALTH
Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal
System at:
'---'... --------'-'-----'--- --'--'---'-'---- ----------'-----------------'-------'-'---------'
Location d¥ss r z�z�
axm
4dress
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Installer A Wdess
Type of Building Size Lot Sg'
feet
Dwelling of Bedrooms ........ z� .--------------'Ezououioo
Attic ( ) Garbage Grinder ( )
Other—Type of Building -------------- No. c6persons ............................ Showers ( ) -- Cafeteria ( )
Otherfixtures --------------------------_-----------------------------------------------'
Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank --Liqoid' ............ gallons Leoeth--------Width ................ Diameter ....... --..... Depth ................
Disposal Trench --No. -------------------- Width .................... Total Length .................... Total area .................... sq. ft.
Seepage inlet
Pit No --------------------- Diameter .................... Depth below- Total ft.
Other box( ) Dosing tank ( \
Percolation Test Results Performed bv.......................................................................... Date ........................................
Test Pit No. l ................ naiootcuperiocb Depth of Test Pit .................... Depth tvground water ........................
Description ofSoil ............
Nature of Repairs or Alterations P �X'
The undersigned agrees to install theufore6escribed Individual Sewage Disposal System in accordance with
the provisionsofSLIIIE 5 of the State Sanitary Code—Theoodersignedforther agrees not toplace the system in
operation until a Certificate of Compliance has issued by the board of health.
eo Signed. _T.0 --- -- --------
Date
ng
Date
BOARD OF THE COMMONWEALTH OF MASSACHUSETTS
OF HEALTH
z-1................... .------..----
of Toutlifinurr
CERTIFY,THIS IS TO the od;vidoal Sewage Disposal S7oteuo constructed ( ) or Repaired (/)