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THE COMMONWEALTH OF MASSACHUSETTS
BOARD7F HEALTH
ttN ................. OF ........ .. 40.
.............................................
Appliration for Disposal Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at.
............. . . ..... ................ ..... WE: ... Ui 10 .... . . ..... n-
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L cation -Address or Lo No.
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Installer' Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ............................................Expansion Attic Garbage Grinder
Other—Type of Building ---------------------------- No. of persons.._._..__..__......._._.._.. Showers ( ) — Cafeteria
Otherfixtures ........................................................................................ __ ..........................................................
Design Flow -------------------------------------------- gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity ............ gallons 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 .................... Date ........................................
Test Pit No. I ................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 ........................
Descriptionof Soil ...................................................................................................................
..............................................
Natumof Renaixs or -ARV
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Agreement: I S
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I TU 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee suyy e t
the,y6a�UJO h
Application Approved By
Application Disapproved
a
. ........ .........
ate
. ...........
Permit No:?L,1,0,� . ..................................... .....................
nate /
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... .......
........................... OF.. Y ............. . ........................................................
(Intifiratr of Tontliftaurr
T is TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired (X)
byfg,7,10
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Installer
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has been installed in accordance with the provisions of TjTe:P, 5pj The State Sanit ode a Qdescr' ed;' e
application for Disposal Works Construction Permit No --------- ----------------- dated. ......... ................. j ---------- ----
A-, -UA�i#NTEE THAT THE
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS.-,.-,
SYSTE
!f)WILL 1UNC,10 SFACTORY.
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