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THE COMMONWEALTH OF MASSACHUSETTS Fps. .
BOARD OF HEALTH
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Appliration for Uiapoiial 10urkti Tnnitrurtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
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oc on - Ad ress or Lot No.
...................•-..... --- .-- ' 422 '--......................... ........................ _...........---•-•------------.------.---....----..
/O`w'ne Address
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. 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 Repairs or Alterations —Answer when applicable._fir%/_ . .L.�ll��
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of �1T
p 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..... ---------------------------------------------------------------------------•-•--•- ..................
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Application Approved BY - Date ........................................
��hh 1 cer Date
Application Disapproved for th�"l�2i1yfreasons- --------------------------------------------'-------'-----------------------'-------•------•----------•-'•------
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Date
PermitNo ......................................................... Issued --------------------•-----------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
(9rdifirttfr of Toutplittnrr
THIS IS TO CER-TIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( �
b ;1'
1, Instal`
at---••------ •... ✓ L ' .._.. f -T i! ` =� f w -' � "� -----------•-------------
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has been In .11edYin accordance with the provisions of TI"'I4 j of'The �St to Sanitary Code as despribed inr the
application„for Disposal Works Construction Permit No. A..” f __ .f _____.. dated..., ;_.___ may_______________ _
__._
THE ISSUANCE OF THIS CERTIFICATE SHALE NOT BE CONSTRUE® AS A GUARANTEE THA THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................•----------•-----.............-----------------......... Inspector