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THE COMMONWEALTH orMASSACHUSETTS
BOARD OF HEALTH
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�� �«�mm�» spasa� Works Tonstrurt0on Famit
Application is hereby made for u Permit to Construct ( ) or Repair c-)—.t5
Iodivi6nal So~ugo Disposal
System at:
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---- --------7r_~~~~°_,°~~�_~___+______________`___
Location - Address
or Lot No.
----'---'-----------_---------------------------- ....................
Address
........... _________________ ______,��_~a__, J`*"^�~�^����____ _____
z"m"xer Address
Tvnc of Building Size Lo
t Sg'
feet
Dwelling of Iedcoono--Z................................. Expansion
Attic ( ) Garbage Grinder � )
�C�thor--T`me of Building ............................ No. cfpezu000-------------- Showers( ) -- Cafeteria ( )
^� Other ' ... ........................................................................................................
�lovv---'--.~�''���----'----��lmuv per ��rxoo per do�. Iotu du�v 8ovr..''���'��'���--------' .
Septic Tuo�--��o�l�capacity --'. gallons Length ................ Width ................ Diameter .------- Depth ................
Disposal Trench ---'Iot�I.co�t6---Totalleaching area ft.
Z17 --
Seepage P� l�u---.--_.. D�zo�cr—'/����.- Depth below �leL-'�...'-'--Total leaching areu-----'-'-. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-
Percolation Test Results Performed bv.......................................................................... Date ........................................
Test Pit No. l ............... minutes per inch Depth of Test Pit .................... Depth toground water ........................
44 Test Pit No. 2 ................ minutes per inch Depth of Test I,it---------- Depth toground water ........................
-. ............................................... .................................................... .........................................................
0 `Description o{Soil ........................................................................................................................................................................
..................................................................................................................
Nature of Rep�irs or Alterations — Answer when applicable ........... en f.. �2 ...... 71'
The undersigned agrees to install theoforedmcribed Individual Sewage Disposal System in accordance with
the provisions of T I T U, 5 of the State Sanitary Code — The undersigned fulthe s not place the system in
operation until a Certificate of Complian as een the a.d alt
'7 ..........
Date
ate
THE COMMONWEALTH orMASSACHUSETTS
BOARD OF HEALTH
Trdifiratt af