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THE COMMONWEALTH OF MASSACHUSETTS
ARD OFHEALTH
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,� rltr ton
-for 15i,ipoi I orko Tonotrurtioo Vrrm t
Application is hereby made for a Permit to Construct ( er Repair ( ) an Individual Sewage Disposal
System at:
C__t� vT------------------•--- ......
Lo ea 'on - Address or Lot No.
----- l`a /7 c 1 �� c ' `T-----'� 1'.ope_'
Owner Address
--- ...
Installer Address
d Type of Building Size Lot /_7S ... Sq. feet
U Dwelling — No. of Bedrooms____ ................................._Expansion Attic ( ) Garbage Grinder ( )
aOther —Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( )
Other fixtures _______________________________ �i%���
W Design Flow --------- %ld_______________________gallons p //_��ge�serr per day. Total dail� flow.___.___._____ ._ ��___ ______gallons.
�i'
WSeptic Tank —Liquid capacity/ gallons Length____._____ Width___--- ------._ Diameter________________ Deptlt__`�________...
x Disposal Trench — No_ ____________________ Width .................... Total Length --------------_---- Total leaching area .................... sq. ft.
Seepage Pit No ..... /----------- Diameter__. Depth below inlet_.Total leaching area.Z �___sq. ft '
Z Other Distribution box ( c4 -"Dosing tank ( ) SW y<1g���
aPercolation Test Results Performed by .... lti .......................... Date_1 /_
Test Pit No. 1___r— _Z -__minutes per inch Depth of Test Pit/_�,l
____ Depth to ground water-
(_ Test Pit No. 2________________minutes per inch Depth of Test Pit .................... Depth to ground water=v�iE�'%
-----------------------------•-----------------------•---------------------------------------------- -----------------------------------•------•--------------
Description of Soil--------- -------------------••-----
............ ............................... ----...................................................................................... ---•--_----------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------• •--- _-------------------
Nature of Repairs or Alterations — Answer when applicable .-_________________________________________________.................. _--------------------------
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Agreement :
The under=4�KoT'the
s'r install the aforedescribed Ind* viduaI Sewage Disposal System in accordance with
the provisions oState Sanitary Code — T u dersigned further agrees not to place the system in
operation until a Certificate of Compliance has been • su byll oard of health.
Si e- -- ----- Q
=U L/ -------------------- ----------------
te
Application Disapproved for the following reasons:-------•---------------••-•--------•-•--------•---•-•-•--•-----•----------------- ---------•-•--_----------•-
-------------------•--•-•-••---•-•-----•--•-------------•---•-------••-••-------•-•--------•-••••••--•--- I-----------------•-------------------------•----•-----•----------•--------_........------_•----
Date
PermitNo --------------------------------------------------------- Issued ........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.OF...........i <>�
/.:.e%.rt1.f ...:a./..........................................................
Trrftfirat� of (P IMplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed _(C ') or Repaired ( )
b =f==
L Install r
at --�. --•- ... --- --- ----- -- = -------------------------------
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has been installed in accordance with the pr visi s of �Crti of Thee �amtary�Code as described in the
application for Disposal Works Construction Permit No
..` r _____._._ dated_,._w _--_ _ ____________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE_ .............................................................................. Inspector ........................................................ ---------------------_---