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THE COMMONWEALTH OF MASSACHUSETTS
j �%OARD .�O/F HEALTH
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Appliration for Disposal Works Tontrnrtion jhrmit
Application is hereby made for a Permit to Construct ( ) or Repair ()�) an Individual Sewage Disposal
System at:
�'----••••- ... • . -.: ....:
...... _-----.-•----.:5L----------.M ....................
ocati Address or Lot No.
.................... --r- - ,� .--•------•---
ner 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 ( )
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. 1................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... ......
----------------------------------------------•-------------------------------------------•--------------------------•------------------------------------------...-----------•-••--•--._...-----•....
Nature of Repairs or Alterations — Answer when applicable_ ��.. _. A/ .__�Qyo /c...
J4•---------- --------•---•-----------
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 been issued by the board of health.
Signed .............................................................. ................................
Date
Application Approved BY--,:x�/-• f /��"-8----- - - - - �-•................................. ........................................
OlC Xng r as Date
Application Disapproved f o 7 o ng edsons- ---------------•----------------•------------------------------------------•---••-•---------------._.......-----
•....••-•-•-•----•------•-...---•-----------•-----------•-•-•----•---•-•--•---••••--•---------------------•--•--•-----------•---------••---••---... ....................................................
Date
PermitNo ......................................................... Issued .......................................................
Date
THIS
THE COMMONWEALTH OF MASSACHUSETTS
%:BOARD OF HEALTH
/.!!........OF..... /� f.�c..................................................
Trr#ifir ... of T-amptiattrr
RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired)
at -----1 tN %-� ------ -/�C _/_----------•-----------------------------------•-----------•-•---.----------------------.--••--------------
has bee installed i accordance with the p ovisi ns of TIT' 5 of The State Sanitary Code as descr' e n the
application for Disposal Works Construction Permit ti'o __ "r,�Q___________________ dated --- ,;"'��>_ __ ___��_...--......
TIME ISSUANCE OF THIS CERTIFICATE SI AIL NOT BE CONSTRUE® AS A GUARANTAE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector