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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.................._......................
Appliratiun for Diupuuttl Works Tonsirur#iun 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:/_i.. .....= .........
C o _ .
�io}i - Add 's� or Lot
Owner 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 ( )
Other fixtures .
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 ........................
Description of Soil
...............•--......----....----------------...---•--...-•-------------........--•-----.._...••--._._......-------••••.._...------........-•---Z
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.......................... ••.......................................................................... .
Natureof Repairs or Alterations —Answer when applicable . ...................... ..__. h,-!J____._......L___
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIS, 5 of the State Sanitary Code — T;h,.--,,-s,
and rigned further agrees not to place the system in
operation until a Certificate of Compliance has bee d band oi alth.-Sig .d_ .. ...............
----- ----
---- ••---- ..................
Application Approved By . . - l 7. =
Date
Application Disapproved for the following reasons: ------•---------------------------------------•-•--••-•-------•---....--•---....------..._..............._------
..............................•--------•------------•••----------••-•----------•------•------•--•-----•----......................--------•-••-••••- •-•/Date----------•.....------....
.............. No....11-.T -: 6Y4 .----...---•----------.. Issued.
e ...............................
THE COMMONWEALTH OF MASSACHUSETTS
�.� BOARD Of HEALTH
1'
........... u:�2.� .......... OF ........... ./..`�:� ( .'........................................
(Intifiratr of TI-I mplittna
THIS IS TO CERTIFY,,That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...................... Ys. a"-wZ Z. L , ...... ----- ......------------•-----.... ...........-----.....----•-----
at. .... 7 c� (�-------- 1 Installer /
has been ins led in accordance with the provisions of TITLE of The SJa.te Sanitary Cr e as described,/in thr-,
application for Disposal Works Construction Permit iv'o.___.-i _...... dated__-..._.._1/.//.5._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARNTEE'THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. t -
DATE...... ....L?� ................................ Inspector4��- .._�-