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�� K� �� HEALTH
Appliration for Dispaiial Work,5 Tvustr��n ramit
Application is hereby made for u Permit to Construct ( ) or Repair ivklual Sewage Disposal
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orLot No.
---------~-� ----------------_-__-'--........................................
Addr ss
............
Installer --------------------' -------------------------------------------------
z"m"lle, Adaress
Type ofBuilding Size Lot_ 8o feet
Dwelling --No. of Bedrooms ............................................ Expansion Attic Garbage Grinder ( )
<]8z«r--Trnw of Building -----------'-- No. ofperuouu------------_' Showers ( ) -- Cafeteria ( )
Otherfixtures ............................................................
Design Flovv---------------'-----'�aDooa per person per day. Totaldaily flow .--------------- .
Septic Tank—Liquid capacity ............ gallons Length_ ............. Width ............... ' Diameter -.------ Depth ................
Disposal Treuch--DTu----------Widt6---.------'Iotal Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ................ Diameter .................... Dcu16 below inJct---'---'--' Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed 6r.......................................................................... Date ........................................
Pit No. l-----'-'. minutes per inch Depth of Test Pit ---------' Depth to ground water .................... ,-
Description of
___----............................ -__-_-__'
Nature of Repairs orAlterutioo—Answerwheo
Agreement:�
The undersigned agrees to install the uforedescribed Individual Sewage Disposal System inaccordance with
the provisionsofTIT TIE 5 ofthe State Sanitary Code — The undersigned '6������u��P�e the ��m�
operation ��uCert���� h���i�o�>ythe 6���bealth.
Application Approved By ........... 'ajfe... )L ...... :s.5r.) ........ ...............................
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----`------------------- ------------------`-----`--------'—``------
� Date
Pero
resooMMowvvEAcrHoF MAesACxussTrs
BOARD OF HEALTH
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'_-'.��,�.�ux+x OF^�'++^���+'~-+-^-----''-'
THIS Individual Sewage Disposal System constructed ( )or Repaired(�^1
/
has been installed in accordance with the provisions of TITLE 5 of The State Sanita �d Ze d *b�djn the
application for Disposal Works Construction Permit No ...... ;'/-a ------- --- 7 ---- ry C esc� . ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A A �A
SYSTEM WILL FUNCTION SATIS FACTORY.
Inspector