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THE COMMONWEALTH OF MASSACHUSETTSel
�HEA BOARD OTH 1 �7�
..... OF .... ... .----------------------------------------------------
Appliration for Uiipu, l al Warks Tomilrur#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
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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 ( )
Otherfixtures-------------------------------•----------------------•----------•-----•-------- ------.--------•••-.....--------------•--••---•-----._......-•------
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 ..................
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ature,of , pAirs or Alteration — Ans r when applic _-df_.,
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Agreement :
The undersigned agrees to install the of r described Indiv
the provisions of TITLE 5 of the State Sanita Code — The un
operation until a Certificate of Compliance has n ishued )' th54
Application Approved By PP P -----------
Sewage Disposal System in accordance with
ned further agrees not to place th system in
of health.
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Date
Application Disapproved for the following recon: ----------•----------------------------------•-----------------------------------------------------------
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........
Permit No. - �---------------- Issued v& •-----------
ate
THE COMMONWEALTH OF MASSACHUSETTS
by
BOARD OF HEALTH
................................. I... OF .....................................................................................
Tntifiratr of Toutplitaatrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
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 OT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector...---------------...-----------------------------------------------