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THE COMMONWEALTH OF MASSACHUSETTS
�, BOARD O HEALTH
1.om............. O F........... r ;
..................
FEs..! .....' f'
Applirationt for Mgpooal Works Ton otrn ions 11trutit
Application is hereby made for a Permit to Construct ( ) or Repair (j/)/an Individual Sewage Disposal
System at: �:. ...
Location - re
QOwner (J�,��'
...... ...............................
Installer
Type of Building
Dwelling — No
Other — Type
Other
Lo7"_ 5 .... .•.....-•-•.._____-•--.........
or Lo 0
Address
J�
Address
�/ Size Lot ............................Sq. feet
of Bedrooms .................. 4�.................. Expansion Attic ( ) Garbage Grinder ( )
of Building -------------------_------ No, of persons ............................ Showers ( ) — Cafeteria ( )
s........................ .
Design Flow...........................................gallons per person per day. Total daily flow. ........................................... gallons.
Septic Tank—Liquid capacityli d...gallons ,Length ................ Width..-. -._-. -- Diameter ............... DL pth................
Disposal Trench — No. -.../--------------- Width --- g............ 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 ........................
Description of
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Nature of Repairs or Alterations — ns when applica�e /OOd ��
Agreement:
The undersigned agrees to install the afore e. ribed Individual S a e Disposal System in accordance with
the provisions of TITL. 5 of the State Sanitary de — The undersi a urther agrees not to place the system in
operation until a Certificate of Compliance has b issued the bo d hea V.t�'
gned....... -- --•-.......... •.... ........................... ------ -•-- ....'�......
Application Approved By..---- . ------------------------•--............ -•--- �� �-_---- --
Application Disapproved for the following reasons: ........... •--•----•-----....................
.......
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.--------------•-•-------.._...-----••---••-------•-,� ---•----•--...._.....--•---.......-----------••------------•---•----•----
qq -
Permit No..._... C...-- . ................... Issued-.-----------
Date _...— •�... -....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,
........ ,!�✓li-- ..... O F....... -�:: dna/r,:'.''...........................................
"I (Intifirato of TonwHatta
TH ,S 6 C TIFY T at the Individual Sewage Disposal System constructed ( ) or Repaired
by'' .:----- -� .',E..... ..... ........ . ---,-.............................. --......................................................................
•• _
at ... -r r-�_stauer
�t
has been installed in accordance vSith the provisions of Tl`� S off Thi State Sanitary Cdg as. de'cr}bed in the
application for Disposal Works Construction Permit No.... dated ----- ../j% -__ j_�J�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE. Inspector---- iiA "`�.-----•-/-----------------------