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THE COMMON1h/EALTH OF MASSACHUSETTS
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BOAeRD F HEALTH
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Application is hereby made for a Permit ta Construct � or Repair O an Individual Sewage Disposal
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� Installer Z��S �ue ��1� Address .�Q
' � Type of Building �� �'S7 ize Lot
' Dwellin No. of Bedrooms----..����2� j�•�t�'9 _.J�---S !.�`/ -- ------Sq. feet
�-, g— ______________Expansion Attic (� Garbage Grinder (-�-'�
Other—T e of Buildiii __._._.___"-_.'-"_.____ No. of ersons____________________________ 5howers --� —
� YP g P _ ( ) Cafeteria (--}
� Qther fixture ----=--------- ------------------------------•------
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W Design Flow_____________� _........___________..gallons per person per day. Total daily flow__._.__.���_________....._._._gallons.
WSeptic Tank—Liquid capacity,��'allons Length...._.___"'_-_. Width__.__._�---:_._. Diameter...—_______ Depth__`_.____.__
x Disposal Treuch—No. .._.__._.".-'_..... Width___.__�..__..______ Total Length.___._._-.—._�,.._. Total leaching area_______________ sq. ft.
� . Seepage Pit No._._.�._______._ Diameter...f�Q.__._.__ Depth below inlet.___.�...._..__ Total leaching area.� ..�'. _�___sq. ft. ,
z Other Distribution box (�) Dosing_t�nk ) '
'-' Percolation Test Results Performed by..---_�/._�f,��'��""�""_"'T"--f�- ---•------- Date._--����,��---------. '
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� Test Pit No. 1___._�_.___minutes er inch De th of Test Pit..�_ _j..��_
p p _ Depth to ground water..__.�V____...
' f=, Test Pit iV'o. 2.____"'�"_____minutes per inch Depth of Test Pit.____..'—'.______._ Depth to ground water...__''.-______.____
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Description of Soil____Q_"��.____�e�._ ..���/�_..___
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V Nature of Repairs or Alterations—Answer when applicable.______ '
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greement:
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The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
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the provisions oi :�: �_.:. 5 oi the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certiiicate of Compliance has been issued by the board of health.
Signed------...---•----•-••..............•---------------•------------•--•-•-----•----•----•
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Date
ApplicationApproved BY----•-••-----------------•---------•-•------.......-----•-••------------•--.._...._..-----•-------
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Date
Applicatian Disapproved f or the f ollowing reasons---------------------•--•-------------------------------•------•-------------•-------._...--------------•--------
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Permit No.-----(-<-- -�--/--5'------------------------- Issued._..----•-----•------------•-------------..Dau------ '
Date �
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THE COMMONWEALTH OF MASSACHUSET7S -�J—�
BOARD OF HEALTH �
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THIS IS�fJ CER �, That t dividual Se�rage Disposal S�stem constructed (� or Repaired O
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has been installed in accordance with the provisions of TI�' �� j of e St Sanitary Cnd a scribed in the
application for DisPosal VVorks Construction Permit No.__.��_'"____________________ dated___._� ._ __��___._._.______.._
THE ISSUANCE OF THIS CERT�FICATE Sh1ALL PlOT B� ONSTRIlED AS A AR NTEE THAT THE !
SYSTEWI WILL FUNCTION SATISFACTORY. '
DATE----------------•-----------•---------------------....._....-------------------- Inspector..._._._......------------------------------•---------..._..----•------.._._..--••-- '