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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................... OF .................... --................. .............................. _....................
Appliratiou for Disposal Works Toustrurtion prrutit
Application is hereby made f a PerConstruct ( ) or Repair (x) an Individual Sewage' Disposal
System at:
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dress or Lot No.
------------------------------------------------------------------------------- -----------------------------------------
ner / Address
------•---------------••--
nl �.. .....----------------------
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................minutes per inch Depth of Test Pit ...... .__--__._-•--- Depth to ground water --------------_-_----
Test
_-_______-.--_ -__-_._Test Pit No. 2---------- -----minutes per inch Depth of Test Pit .................... Depth to ground water ........................
-------------------•-• • .------------•-----'-------------•--•----------------•---------------•-••--'----•--'• ............................
Descriptionof Soil ------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------.....---'---� ... -� ...
Nature of Repairs or Alterations — Answer when applicable... ...... .......... ...... f_•-- Qx
--------------------------------------------------------------------------�-------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
7 _ T
the provisions of T. _7 -E, 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.
,n ned.
D
�" �� �i Date
Application Approved BY -----•... ' e!�-�
Heal th Officer Date
Application Disapproved for the following reasons: ---•----•-•------•---------------------------------•--------------------------------------------------.....-----
--••--------•••-•------'-•-----•------•-•-•-•---------•-•--•--•----•------••----•----'--'----•••-----------------'-•---•-----------------------•--•---------------------------------•-------------...._
Date
PermitNo --------------------------------------------------------- Issued. ....................................... ...............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ... .................................................................................
Tatifiratr of Toutpliattrr
THIS IS T_Q CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired { )
1 ..
ri— _.. nsta - � --------------------'•------------------------------------------------------
has been installed) in accordance with the provisions of TITLE; j of The ate Sanitary Cgde s des ribed in the
application for Disposal Works Construction Permit No._ dated ----- �.
THE ISSUANCE OF THIS CERTIFICATE SHANOT BEO�STRUE
AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.-•-------------------------•---....------.............--------------------.---- Inspector ....................................................................................