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. ^ THE cowwowvvsxLrH or MAssAc*ussrTs
BQAJRD OF HEALTH
.......--_--_----
for ^�
Application is hereby made for u Permit to Construct ( ) or Repair _L< ao Individual Sewage Disposal
System at:
ner Address
-fltal-l;r Address
Type of Building Size Lot -----'-'--'-'--'Sq. feet
Dwelling --Nu of Bedrooms ............................................ 8t6o ( )Garbage Grinder ( )
Other—Typeof Building -------------- No. ofper000u-------------' 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 Lcog8z---------- Total leaching area .---'------ug [t.
Seepage Pit BJo---_---_ Diaoetor--------' Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .--_-.------_------_---------------- Date ........................................
Test Pit No. l ................ noiootesPerincb Depth of Test Pit---------' Depth to ground water ----- ................
-------- --
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Nature of Repairs or Alterations — Answer when applicable --- — ----
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'TTI. -E, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until uCertificate of Compliance has been issued 6ythe board of health.
Date
'----------Date
Date-
rHsooMMpwWsAcreoF MAssAo*ussrrs
BOARD OF HEALTH
......................... ................ OF .-_-----__--'--.-'---'--_--'-. fill
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THIS IS TO CERTIFY, That thejndividual Sewage DisposalSsternconstructed (or Repaired L�1
staller
has been 'i led in accordance with the provisions of TITFT,' 5 of The State Sa /tay Code as described in the
dat
application for Disposal Works Construction Permit NO_ ed_1_57��
THE I I SSUANCE OF THIS CERTIFICATE SHA L NOT BE C04TRUED AS A GUARANTEE T T THE
SYSTEM WILL FUNCTION SATISFACTORY.
Inspector