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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for Disposal Murks Tono#rixrfi n rrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
..1.` .... T -J -A ... .Q.!�..� ..- r�- �--------_------------------------------------------------------- ---- --•- .................•-•••......._.._..-
Locajion - Addre or Lot No.
Owner Address
....--- l c - ...v... .-- ----- ------------------------------- 1�l �.�G.v-� � �-----... ......... ---...
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 ( )
Other fixtufes .........---•---- ---
Design Flow .................. ................. .... Ilon per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity_..... _;__gal s Length ..............:. Width ................ Diameter ................ Depth ................
Disposal Trench — N,f ..................... Idth... ............... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No.___.____�---------. Diameter_______________ ___ Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution boi ( ) Dosing nk ( )
Percolation Test Results,Perf6rmed by ........ ------•----•••---......•-----••--•-----•--•-----•............... Date--------------------........
Test Pit No. 1 .............. utes 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.
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Descriptionof Soil ............................................................................................
-------------------------------•------------------...--•--•-------------•-----------•--•••••-----•-•----.-- ---------•---------------------------------- --
Nature of Repairs or Alterations — Answer when applicable ..�lrJV �ea� --.- � �.....-- _•--��-.�............................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITA 1E 5 of the State Sanitary Code — The utLdersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued
suueedd by the board of health. �c
Signed... ...... C_._ --•--•------------- --.........................................
% t
ApplicationApproved By ..... .... -.... ................................................................ ---•-- -at! f A.
Application Disapproved for 11ow' reaso ---------------•-•-------•---•--••-----------•--................._....---•--------•..........•----•...------•---
Permit No..... ...". __J - -----
THE COMMONWEALTH OF MASSACHUSETTS
.. ..........
�_«9
Date
BOARD OF
. HEALTH
............... OFL.✓ .V
.....................................
fardifir
faomli�tnrr
THIS IS TO CERTIFY, a the d vi Se a Disposal System constructed ( ) or Repaired (�
bY--.......... .._._..`..__ ..... .. .................... .....
_... ... .
Instal
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has been installed in acc*dance with the provisions of TIT9(V�0
State Sanitary Coe s escrib in the
application for Disposal Works Construction Permit No.....-....... dated.:... .: _r ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE S A GUARANTEE THAT THE
SYSTEM L F CTION SATISFACT `
� y
DATE...... L.�l.1.1u �f ........ �Q.. °t!Y......... Inspector. . ... -...
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