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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
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Appiiration for Dispulitti Works Toustructinn jhrutu
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at: M*i P -4 ( j
--.........!-a: ......... ....'14 - - :: •••.......... ---------- =- --y ...zj...................................
G Location Addr ss or Lot No.
........ .. .........•...•-•............. ......1-..ti��k r* k��4.....!�I.t .. .....
e........ `�1..a.�..:4 ..............••..........�.�.5..... � d ........... ap
Installer Address� �.
Type of Building Size Loti•Sq..feet
Dwelling —No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .................................... &0 -.---•----.--------------------------.... ....
Design Flow ......... I.J.V ....................... gallons pera per 4ay. Total da' iow....-- 1on�.
Septic Tank — Liquid capacity..I�gallons Length.,6%!.. Width....��_Ik..... Diameter ................ Depth.
Disposal Trench — No. ..... #.......... Width .................... Total Length -------------------- Total leaching area........_...........sq. ft.
Seepage Pit No .......... 4......... Diameter ....... tr.._... Depth below inlet ..... 6= ........ Total leaching area.Z6ZL.Q.sq. ft.
Other Distribution box Y,) Dosing tank(
Percolation Test Results Performed b ._...1JQ1...GY...: ................. Date...._._.................._........
Test Pit No. 1 .... .._Y..minutes per inch Depth of Test Pit.... Depth to ground water.1iC......
Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water........................
............. x......................................................... ........... ............... ........................... ............................
Description of Soil ..... 0 =
.... •......................................................................................................................... •.............................
Nature of Repairs or Alterations — Answer when applicable...................................................
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Agreement :
The undersigned agrees to install the aforedescribed
the provisions of. L , ITL 5 of the State Sanitary Code —
operation until a Certificate of Compliance has bee4sod
Application Approved
Individual Sewage Disposal System in accordance with
The undersigned further agrees not to place the system in
by/t board of h h.
Ir Date