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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:............. OF ...................................... .......................... ---------------------_-
Appliration for Dispaiiai Warks Tonstrurtinn rami#
Application is hereby iTde for a Permit to Construct ( ) or Repair (A an Individual Sewage Disposal
System at: C��a
.................... - ...... •------- •--•----- ----- ••------•••-•----- ---• • �QT ._�... U ...-------
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•Loc tion - Addres or Lot No. yy� /� ) 1
Owner
Address
W •_________________________•----
s- ----.....
a Installer Address
Type of Building._.____.._..Sq. feet
Size Lot ................
aDwelling —No. of Bedrooms -•_---___-___-•-__-_______•____--_••_____ --Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
a Other fixtures ............................ .
W Design Flow -------------------------------------------- gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid' capacity.__....._._.gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench —No ..................... Width .................... Total Length .................... Total leaching area ........... ......... sq. ft.
Seepage Pit No ..................... Diameter -___-___•_..____••__ Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
`-� Percolation Test Results Performed by .......................................................................... Date ........................................
aTest 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 ........................
Descriptionof Soil -----------------------------•----------------------_.__---------_..---•--••----------------------•----------------------------------------_--.-..
..._•-•---.---••••---•••-•----------•-•--•-•----------•-•------------•----------•-•--•--------------------------••-•-------•••--•-•----------- ............................
--ZZ
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Nature of Repairs or Alterations — Answer when applicable........ ...� 17A2 7-__ _- _.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of '11"TIE 5 of the State Sanitary Code — The undersigned further agrees not. to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig -•---
Si�.a,a.Pp D
j ; � �' 4 Date
Application Approved By " V 7 y �Cc ~vim+ •----------- :------------------------
�ea'1-th--0-ff-f4-eE'-r"-•------------------------------------------------------- Date
Application Disapproved for the following reasons:--•-------------------------•--------------------------•---------------........................................
..................................................................................................................................................... .............. -------
Date
PermitNo --------------------------------------------------------- Issued -------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ....................................................................................
At
Trdifiraft, of Toutphattrr
THISJS TO CERTIFY,,That the Individual Sewage Disposal System constructed
by ........... (^. E.. e.. a� w �
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has been installed in accordance th the provisions
application for Disposal Works Construction Permit
THE ISSUANCE OF THIS CERTIFICATE SI
SYSTEM WILL FUNCTION SATISFACTORY.
Installer i
�...F ;_ >
�of T
D._ r -
LLL NOT BE CO
DATE................................................................................ Inspector.......
or Repaired OC'
Sa ry Code as described in th
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AS A GUARANTEE THAT THE