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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for Disposal Works Tonstrurtion tIrrmit
C_ Application is hereby made for a Permit to Construct ( ) or Repair �X an Individual Sewage Disposal
_J System at: _ /� 7
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or Lot No.
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Address
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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 ( )
Other fixtures ..
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....................
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Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil--------------------------------------------------------------------------------------
Nature of Repairs or Alterations—Answer when applicable _.x.1 11 _-',r�..�C1.._. /.
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI5 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 he board of health.
Signed.. . ........................................ _....
Pate
Application Approved By. ,�- :J'P-1 ",F'......
Date
Application Disapproved for the following reasons:---•-----•------------------------------------•--.......------......-----------...._....._.....•-----......•....
-----------.-------------•------•--•--------......------------•---------................•••---....--------•--._......---•---------•--.--••-----------------......--------...._....
._.........................Date
Permit No.....c���....:2,__ , .f ••------------•••••••• Issued ....•••. .-�. �
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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(Intifirab of outpliancr
THISTO GE TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
./
/ r._..._..._. InstC
at .............. 1mm
PP 1 _ l� dated ......... !describe¢ in the
application location foreen 11Dlsed 1 osalcWorkseConstru tum Permit �with the provision.-, fo:,___._�^ __ of The _State Sanitary Code as -/l �:'� • -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A.GUARANTEE TH11 AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ....... ,t...._r ----------- C .........
Inspectors-- �=-"----`-==------•-_----------....,: '•'----.. �'' .....---•--•-