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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CJ�'1,—.......OF.... (\_ F� _ (f M 0
.......................................
, pplirationt for Disposal Works Tonnsirurtiont f rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (individual Sewage Disposal
System at •
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L,'iTVis, .�.. 1Z}
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Location ddress or Lot No.
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Address
---- -----
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ........... 3 .............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building --------_----------------- No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-----------------•------------------•---------------...---•------•---••-•--....._
Design Flow ..... .......................... 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 ......... 1.......... Diameter.._... .... Depth below inlet ... Total leaching area..................sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. l................minutes 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 ........................
--------------------------------------------------------------------------------•-•-•---------............................I
Descriptionof Soil ......................................................................................................................................
-----------------------------------------•-----•----------------------------------------------._...-------•------------------------•--•-
Nature of Repairs or Alterations — Answer when applicable ------ . ?!,....... `-_>�6i........ �'�%�.._c�s.l�..j....
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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 Compliane , issued by the bo
Signed. -- -- ..... --- I��
I... _
ApplicationApproved By..... -- ..... ............ ....................................................... ........... /.. /1e1� _
Application Disapproved for the f ollo g rens s----------------••------..._...-------•----------•--•-----------•---•------•------------•--•---••----.........._
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/ l ` Date
Permit No....... SL� - - -------....----•---------------------- Issued........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..' . ...:....................OF........ • 't:... f:..F :........... '1......_...........................
Trrtif irate' f fl�unt�r�ittntrle
TbtJSJS.-TO CE9T4F_r, .That the Individual Sewage Disposal System constructed ( ) or Repaired
-.
Y ................. :....:....... ........ .
at................ ....:..............
.:..e.�r: -'.............................................................................
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has been installed in accordance with the provisions of TITLEE 5 of The State Sanitary Cod as,described in the
application for Disposal Works Construction Permit No._��CONSTRUED
�iA/NTEE
�PP 1 -----------•-- dated -THE ISSUANCE OF THIS CERTIFICATE SHALL NOT EAS A THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ........ -�'... -.� �-----------------------------------------
_.---- Inspector ............ _.�......f _ ..•--..:::�:::..__
._-.–.