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THE COMMONWEALTH OF MASSA SETTS
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Appliratinn for Dhipvoal Works Tonotrnrtiunqm' 'i#
Application is hereby made for a Permit to Construct () or Repair ( } an Individual Sewage Disposal
System at:
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2 ( Lo tion -Address es S u- O r Lot � - A /
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Installer Address
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Type of Building Size Lot .-_I.a-1 4-AC2--Sq. feet
Dwelling —No. of Bedrooms.. .......................................... Expansion Attic ( ) Garbage Grinder ( )
'4 Other — T e of Building ............... No. of persons......_..................... Showers — Cafeteria
Other fixtures .---_-_-----------------_-.'w .., _ .
.. •---- -----------
W Design Flow ................. �__.�_.0............... gallons per per day. Total daily flow___----•.-�_ .�.................gallllons.��
WSeptic Tank—Liquid capacity.l.� �allons Length_�_-� Width.+'.'10_ Diameter______________ Depth_.5__.. .
x Disposal Trench — No ..................... Width .......... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No........I.......... Diameter ...... �_.C)..... Depth below inlet ....... (zt....... Total leaching area -_�.-7..sq. ft.
Z Other Distribution box (� Dosin tank (_
a Percolation Test Results Performed by _._,_.. � ...}_../........__. Date ..... �_�7.._.. ;;0 ..............
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Test Pit No. L. _._minutes per inch Depth of Test Depth to ground water ........................
f=, Test Pit No. 2...._._.�nu'nutes per inch Depth of Test Pit .... lDepth to ground water ........................
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............................................................._ ... `� -----------------
Des ir�iptioii of oiL0_'!-.&0 �-P..... -. �aC?S So ��'� QII-.-.a�------M. �" �`� � �5d_i_�- ........
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U Nature 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 undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beenA*ued by the board of health.
Application Approved By
Application Disapproved for the f ollozuiing reasons:
Permit No....... -? ..- ==5 -•1-----------•--------
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Date
- % .�
) j
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Date
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Date
Issued--------' ............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... ' ''................... ................................ ........
Trr#ifirabe of Tantlilianrr
THIS, IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
b/. . ..... / f c.. •---•-•. ----------•-------•--------------------------------------------•---•------._...-••--•----•••--
Y Installer
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has been installed in accordance with the provisions of TT,TLF 5 of The State Sanitary Code as described in the
17
application for Disposal Works Construction Permit No _ ...................................... dated_' ......................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE......1. _ :--------------•---------------------------------- Inspector..... - 2 ..................