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. THE COMMONWEALTN OF MASSACHUSETTS
BOARD OF HEALTH
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Applica6on is hereby made for a Permit to Const:uct (X) or Repair ( ) an Individual Sewage Disposal
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� T of Buildi aaar<:s �7 p
U 3'Pe �$ 3 Size Lot_.1_�.t�i,�_Q__.._._.Sq. feet
a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grsnder ( )
aOther—Type of Building ......................._... No. of persons.........._.__..........._ Showers O — Cafeteria O
! � Other fixtiye ---------- - --------------------------------------------------- �------�-----------------------------------------------
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W Design Flow---------------r}-- --------•-----gallons per person r day. Total daily flow_.___•----- -�--------�------ �OIIii
' W Septic Tank—Liquid capacity.��.QO.gallons Length_ �-- � �-
�..lp.. Width�F.._-�.d. Diameter............... Depth_.��...._8..
x Disposal Trench—�o--------------------- Widt -_-'-i------------- Total Length.---------------a- Totai leaching are�------------ sq. ft.
� Seepage Pit No.___.____�....._... Diameter....._�.Q........ Depth below inlet.._....�r______. Total leaching area.��....sq, ft.
z Other Distribution box ( ) Dosing )
a Percolation Test Results Performed by-----_�T�A1L�...��-� j������Date-_---I-��-�-�-�-�-�--__----..
� Test Pit No. 1......?i..__.minutes per inch Deptli of Test Pit..�._.�...�.�_._ Depth to ground w ter......I�Q/�.�..-
j k, Test Pit No. 2......_�._minutes per inch Depth of Test Pit_._��!k.._._.. Depth to ground water...__�Q�.�
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'' � Description of Soil----�e-�----••��i_�S-�i_..�.Q-_---.- ----��-----..��11_8�-�-�`---- -.�A._�....L- --4t�-----
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V � Nature of Repairs or Alterations—Answer when applicable................��_l+l�______...... . ......_._.._.__......._____.
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a�SCCR1CIlt: �
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
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� the provisions oT .�::s. 5 oi the State Sanitary Code— The undersigned 2urther agrees not to place the system in
operation until a Certificate of Compliance has b ssu b ealth.`
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!, APPlication Approved By - -• -----�-- ------------------i--.... --- ---- - - �Z �ID ----- -----
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; Application Disapproved for the foldowing reasoxs:-------��------------------------------------�----------------------------------� -----------..._-
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PermitNo......_�.l.��O�---------•-- Issued.'-- !X� I• --��L;14
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�i THE COMMONWEALTH OF MASSACHUSET7S
� BOARD OF HEALTH ,�
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THIS I TQ CEKTIFY, t the I dividu Sewage Dis osal S;�stem constructed �or Repaired ( )
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' has been installed in accordance with the provisions of TITI,E 5 of T e Sta Sanitary Code as scri ed in the
; application for Disposal Works Construction Permit No..__._.g.�'-_..�.t�� dated_.__.C�.�. ../.�. ._.�__.f._
THE ISSUANCE OP THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARATITE TFIAT TNE
SYSTEM WILL FUNCTION SATISFACTORY.
. DATE...................••--•--........-------_......--•--....._-•---••••••---__ Inspector_....••-----....------•---------•-------...------.....----......__.
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