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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
i
1
A'pliratiun fur Eliuixuuttl r r;urk Tuttstrurtinn tirnitit
Application is hereby made for a Permit to Construct (/) or Repair ( ) an Individual
Sewage Disposal
,4t/to System i
..)
Act 1 /12670
v`!.[ 4 L 21;:-Address S�f�T or Lot No.
a T 044-/ _�lnI Address
Installer Address
Type of Building Size Lot Sq. feet
,-1 Dwelling—No. of Bedrooms.... Z �- Expansion Attic (' Garbage Grinder ( )
aOther—Type of Building __ YJ1. ,...._._ No. of persons Showers ( ) — Cafeteria ( )
d Other fixtures
Design Flow �/eQ gallonsperpersonper day. Total dailyflow
W gallons.
W Septic Tank—Liquid capacity)C0allons Length_.._ ' Width I' Diame er 4� De th f`
M
Disposal Trench—No. Widthf-�_ _.Y Total Length f Total leaching area_. sq. ft.
Seepage Pit No 'If Diameter AGJ Depth below inlet 4 Total leaching area-"$3 -- q. ft.
Z Other Distribution box (1 ) Dosing tank ( )
a Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
(s, Test Pit No. 2 minutes per inch Depth of Test Pit De th to gro water
I:4
0 Description of Soil
W
UNature of Repairs or Alterations—Answer when applicable.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersig!ed f grees not to place the system in
operation until a Certificate of Compliance has been issued b th oard op r
Si ned / r�1i
Application Approved By ` Date
Date
Application Disapproved for the following reasons:
Date
Permit No ... Issued.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /v6 AS Goy
OF
Olrxtifirtttr of (ttuntplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by
Installer
at
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector