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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H,rALTH
........................................... OF......L.. .......................................... .............................
A#11ration fur Disposal Marks Tunotrwtiott 1 rruti#
Application .is hereby made for a Permit to Construct ( ) or Repair ( L�an Individual Sewage Disposal
System at: eV
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✓ �/Y C3 v e.G . A res...............................»... ._... ... ...»or .Lot-No........
..................... »».......
» - O: -�... -Address ....--•---- ---.».»......»..»»....
.Inoe
tll-Address
Type of Building Size Lot............................ Sq. feet
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Dwelling No. of Bs.........................................Expansion Attic ( ) Garbage Grinder ( )
04 Other — T e of Building - o. of persons ............................ Showers
a YP - P ( ) —Cafeteria ( )
dOther fixtu... ••• •-••••......--•--•-•••••••••-•---••.••••...............•••••-••••-•••-••......••-•---••-•••••••--••••••...........w.-•---•-•-•-•••-
WW Design Flow ..... .................--- s per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid ca.•..•. gall s Length................ Width ................ Diameter ................ Depth ................
Disposal Trench — No. .. Total leaching area .............s ft.
x Po idth Total Length.._.. g q•Seepage Pit No................ er.__........._..._.. Depth below inlet.............._..._. Total leaching area.--.........._....sq. ft.
Other Distribution box (Do ng tank(Percolation Test Resultsrformed b ....................... Date.....•.•.--..•..........____.......__...
Test Pit No. 1..........utes 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 ........................
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ODescription of Soil ............................. ----------------------•--•-•-------------•-----••------------•---....----•----------•--------...........------.....................•••---
•-•-••••••••............••-•.....•••••••-•...-•••••••--•••.....••••-••••-------------••••••-•-•••••--------....•-------------•--•-
U Nature of Repairs or ` �raios —Answer when applicableZ� -- f--���.._Q - -----------------------
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--------------------- ... .C- - -.-s ••••••-•••-••---•••••••....••••-•-•....-••••-•.......•••.......----•---••-•••••-•-•----•••••••------•--•-...................-•-•--.....----
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 Complian a has been issued by the board of health.
--._....- ------ • --
at
Application Approved B -..... .................
PP PP Y.....- • -• ••. •-•.............. ....--...... _.
Application Disapproved for the ll 'ng reasons:---•---••-----••-------------------•---------------•---•----------------------------......•.
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Permit No.5........................ Issu sng
Date-._..-
THE COMMONWEALTH'OF MASSACHU5ETTS
BOARD OF HEALTH
.............OF �` . ..............................................................'
Teri fzra of font r� tttr�e
THIS IS TO CERA h the I;4,vidjaid Sewage Disposal System constructed ( ) or ( Repaired
by................. ..... .. . f�l._:....1 ..<-.! ...--.....- - -
taller
has been installed in accordance with the provisions of TLZLE rr,Qf The State Sanitar de a ,��esc a he
application for Disposal Works Construction Permit No ? `:--...••-- . -_. dated..
THE ISSUANCE OF THIS CERTIFICATE SHALL H:OT`BE COHSTRUED ASA UARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY
'
DATE......................
' �..»� ...........
........... ..........::.. ........ inspe+�'tQ��"��'r�� ..�
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