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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for Disposal Works Tonstrurtion 1hrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
SXZ6tem at:
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..................
L cation - dr ss y Loth No
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- --..f) cum......................RA_.Y1� ►
)7 �jdress -�y�
Installer Address
U Type of Building Size Lot._ .5. f_.3?7 r2 Sq. feet
Dwelling — No. of Bedrooms -------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
a Other fixtures ---•--_-------_----. -
W Design Flow ••....--..�_�_ 0.........................gallons pe per day. Total d it flow.._......iP?- _.. __..._..___..__._ ons.
�Y
WSeptic Tank —Liquid* capacity)'U A�allons Length..&._-&?-.Width.9'.-./.P �6iameter................ Depth•:�_-¢��
x Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area_ _..._._.____.__.__sq. ft.
Seepage Pit No ......... )---------- Diameter ...... Depth below inlet ------ �o-.......... Total leaching area. 3a?_1 sq. ft.
Z Other Distribution box ( Dosin tank
r
Percolation Test Results Performed b .. � i.._..... �-'L i !v..../.A� .... Date .... - --......�......._.�.. _.
a !� Y }"
Test Pit No. I ............ per Inch Depth of Test Pit.-I.I-�.._.._ Depth to ground water ........................
f=, Test Pit No. 2................minutes per inch Depth of Test Pit ............... _.... Depth to ground water ........................
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Descri tion of Soil ... 0.---• ----- T?.p.... t ...4 ._....... I �—-------------
U Nature of Repairs or Alterations — Answer when applicable...............................................................................................
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the board of health.
Signed_..... '.. - ? --C.-�1-....
� /a;e
Application Approved By ......
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Date
Application Disapproved for the f ollowi g reasons---------------•-----•--•--------------------•-•----............................................................
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Date
Permit No .... •-- "k
a 3�.......................... Issued. ----------•--9- :r. .........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .......!.......................................................................
Tatifiratr of Tontpliatta
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
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Inst�l4er
at= --- ----_ -- -- ------ ----- --------------------------------------------•----------- ------
has been installed in accordance with the provisions of TITLE, --_$ of T e State Sanitary Code-,as>dciscribe�n the
application for Disposal Works Construction Permit No ----------------------------------------- dated ___.____._.-._.__.----:__-________-•---------_-.
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE, THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ....... .......................................... Inspector ....---- --
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