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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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ApplirFation for Diapoli al Warks Tonstrnrtinn Prrmit
Application is hereby made for a Permit to Construct
System at:
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Locatio -Address y
............... :.._._ 1,,,-- .•..--------------------------------
ner
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Installer
or Repair (kA an Individual Sewage Disposal
LUQ/-\K�� Com
. --•-----•-•--•-.-•----•--- Mal
_......--
or Lot No.
Type of Building
Dwelling — No. of Bedrooms............................................Expansion Attic
Other — Type of Building ............................ No. of persons ....................
h fi
.............................. .....................•-
Address
Address
Size Lot ---------------------------- Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
terxtures ------------------------------------------------------------------------------------------------------------------------------
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 Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil -----------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------ -------------------------------------------------------------•--
Nature of Repairs or Alterations — Answer when applicable.__ ----------- . ....... ......7
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT i .;,;. 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.
Sfined._ ....--.......•-----------------------------------------------------------------------------------------
� Date
Application Approved By ............. ---- y. T� p(p�/. ------------------------------------'---
Rea 1 t f 1 of 1 j Cer----•--------' Date
Application Disapproved for the following reasons- ---------------------•--------------------------------------------------------------•---------------------------
....................................................... -----------------...--•..._....---------------------------------•--------------------------------. .............................................
Date
PermitNo --------------------------------------------------------- Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................::............OF..../i4if
.................................................
TertifirttTantilliFatta
THISfi� TO RT Y, That the Individual Sewage Disposal System constructed ( ) or Repaired _(<
--- ��-��-.....-----• - - ----aller ------•-----. s--------------------------------•------....--..............---•-----•-----....
by ............ -- %j, / I aller
at..................4 -��!_ Z .......... ( --------•-----------
has been installed in accordance with the provisio of TIT F, 5 of The State Sanitary Code as descrihe�n the
application for Disposal Works Construction Permit No��.:_._/ ..............
dated_/___:_/.r/_�__//..__________....
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector