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THE COMMONWEALTH OF MASSACHUSETTS
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B0�4RD OF HEALTH
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Apptica6on is hereby made for a Permit to Const:uct (�O or Repau ( ) an Individual Sewage Disposal
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Location-Address o�r y No.
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� Address
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Installec Address
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� Type of Building Size Lot.._.....,��1________._.Sq. feet
.. Dwelling—No. of Bedrooms..............:�'...___._.__..._____...Expansion Attic ( ) Uarbage Grinder ( )
p'�„ Other—Type of Building ............................ No. of persons.....__......_____.____..... Showers ( ) — Cafeteria ( )
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W Design Flow-----_-------------------------------------gallons per person per day. Total daily flow..----_---�:..�.i.'0--_---_---------gallons.
W Septic Tank—Liquid capacity.�ooa..ga]lons Length................ Width................ Diameter................ Deptl�................
W Disposal Trench—:Vo. .........._--.---_ Width.................._ Total Length-------.----------.. Total leaching area.-----------------_sq. ft.
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3 Seepage Pit No.._..�-........... Diameter.o.Z+6�..._..__ Depth below inlet___..��.......... Total leaching area.���e_3..sq. ft.
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' '" Percolation Test Results PerEormed by_ ..._14-�^Ar.<�.._�a:l.!'�k.-..�.fr,�._. Date.._�4t�}:_43.�4'19...
„"�.� Test Pit Vo. 1_L�__.minutesperinch DepCh of Test Pit..._J.��......... Depth to ground water_.N�.i7.e_.......
W Test Pit \o. 2__�_Z_...minutes per inch Depth of Test Pit...�2:5�_.__. Depth to ground water..��n�:___._.
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VNature of Repairs o: Alterations—Answer when applicable-----------------__---_._-----_-------_-----_------------------_.-----------_-_--_-.
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Agreement:
The imdersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions ot:I`i:.: 5 oi the State Sanitary Code— The undersigned furtL•er agrees not to place the system in
operation until a Certificate of Compliance has Ueen issued by the board of health.
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Date
ApplicationApproved By--------------.....---------------------------------------------�------------------------- ---------�-----------�------
Date
Application Disapproved for the following reasons-------------_----------.-------------------------------------------------------------------
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Dam
PermitNo-----------------•----------------------------------..._. Issued...-•----------------------------------------•------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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(�rz�tifutt#e nf fLCurn�littnre
THIS IS� CERTFF�', That the Individual Sewage Disposal S�stem constructed ( �Repaired ( )
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has been installed in accordance wiU� the provisions of 'l�Ji' `p� j o The State Sanitary Co e as escribed in the
application for Disposal \Vorks Construction Permit No....._�/.-.���______..__. dated....I.I_ _�_.`�..��._y..
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THE ISSUANCE OF THIS CERTIFICATE StCALL NOT BE COPISTRUED AS A GU RANTEE TFIAT TNE
SYSTEM WILL FUNCTION SATISPACTORY.
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