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NO.— ............ .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HE�LTH
........... OF ......
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Appliration for Disposal Works Toustrurtion ramit
Application is hereby made for a Permit to Construct or Repair (� Individual Sewage Disposal
System at: � -1
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Location - Address gr t N
........... ... Z�7
... ...................................... 0,
0 .. . .. .... . .....
d s
.............. --------- 0 ................. ..... ...... .. .. . ....... . .. ......... . ... . ........
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 ( )
4 Other fixtures .................................................................................................. 0_00.0 ................... 0 ...... 0 ..................
Design Flow ............................................gallons per person per day. Total daily flow ............................. o .............. gallons.
Septic Tank—Liquid capacity ............ gallons Length________________ Width.__..;._.._._._. I .......... Diameter ............... Depth__._._..._...._.
Q Disposal Trench — No ..................... Width._._........._.___._ Total Length.._._....___.__..... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter........._...._..... Depth below inlet.__..._._._.._.._... Total leaching area .................. sq. ft.
11
4 Other Distribution box Dosing tank
.1 -4 Percolation Test Results Performed by ............................................... 0 ....... 0 .................. Date.:.____._.__.._......______.____.__-----
Test Pit No. I ................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 ........................
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Descriptionof Soil ......................................................................................
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Nature of Repairsor—Answer .-when -appli.(..-a.bi;.N�!;;,---�-4-,
7 . ........ I .......................................................................................
Agreement:
The undersigned agrees to install the aforedescribe dividual Sewage Disposal System in accordance with
the provisions of TLIIPLE. 5 of the State Sanitary Code e undersigne_d further agree not to place the system in
operation until a Certificate of Compliance has been * ue th o Lie
Sign... ........... ....... ..... .. ........ ........................
Date
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Application Approved By__2-w-e �-- --- _-_ ..........
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Date
Application Disapproved for the following reasons: ........... ............................................. .....................................................
.........................................................................................................................................................................................................
Date
Permit No ------ . 4.5
............................ Issued .....
......................
Date I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA
r
............................. ............ 0 F......... . Y®R lWAW e ...........................................................
(Intifirab of Toutplitturr
TH S TO CER h th aiv�o, ual Sewage Disposal System constructed or Repaired (kl_�
by .... �2 e(
-------- .........
....... ................ : ................... . ..........................................................................
.".�..
; -------------
at ..... 1-7 .... ......... .............
2gA ... ....................... --------- �..........................................
has been installedin accordance with the provision. -"- 'T I T LE 5 of The State Sanitary Code as described in the
application for Disposal Works Constructi( .................. dated ........ �W —.01 _. lf_ ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ....................................................................................