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THE COMMONWEALTH OF MASSACHUSETTS
OARD HEALT
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Appliration for Disposal sal arks Zonstrurtion rermit
Application is hereby made for a Permit to Construct (/--) or Repair ( ) an Individual Sewage Disposal
System at:
Location - A dres� or Lot No.
- a�1 . 'e --------------- .-•-........-•---•-••--•....------•--•--... ..........--------------------.............---
. ------ --
�ier ��� Address
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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. 1_ ............. minutesper 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 Soil............
.............................................
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Nature of Repairs or Alterations — Answer when applicable. ..........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 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.
Signed..........................................•-----•------------------...---•------.----- .--- -----••-•-•••-•..
. Date
Application Approved BY ---- -------- ...:.- --- - ----- ------------------------- •---• .
Date
Application Disapproved for the following reasons:-•---•-•--•---------•-----•-•--------•---•-------••---•-•--------•-----•----------............................
- Date
PermitNo --------------------------------------------------------- Issued_ .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Tntifirat# of Tong haurr
THISJS TO CT&R7 FY That the Individual Sewage Disposal System constructed (' or Repaired ( )
_ Installer
at................ ` 1 - --------.
has been installed in accordance with the provisions of TITLE 5 of Tie State Sanitary Code a descri din,. the
application for Disposal Works Construction Permit No ... da ed
...._......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GU RAN E THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector