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No.................... BOAR()
THE COMMONWEALTH OF MASSACHUSETTS
A R® OF. HEALTH �All,
/b OF
Applirttfton for Mivaoal ork C�ort> �x1tr�ion p uttf
Application is hereby made for a Permit to Construct ( -Q or Repair ( ) an Individual Sewage Disposal
System at:
........ .............................. ..._ ( � ! (, t i _
r,
�Locat°on Address ��or Lot No
� ?i
Owner Address
................................................ ................................................ .................................................................
3 Installer Address
i Type of Building Size Lot....: F`I( ;` ....Sq• feet
Dwelling— No. of Bedrooms.......... 11 ......................Expansion Attic
� Other—Type of Building p ( ) Garbage Grinder ( )
........................... No. of persons....................._...... Showers ( ) — Cafeteria ( )
Otherfixtures_ ..................................... ................. ....................-...._........ ....
Design Flow...............- ?:. � gallons per person per day. Total daily flow............ its f ` ... gallons.
t Septic Tank--Liquid capacity t ...= ..gallons Length .L'.'.:�::.. Width t.. Diameter ............. Depth r ;}
° f
Disposal T�rerrch�=Nrf• .._.l fA-• ? .. Width......I. .`....... Total Length......f.tf.:........ Total leaching area.....t. :....sq. ft:
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total.leaching area.................sq, ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by...._ .td�l...i�lS� :.�l�.- :- i
? r Test Pit No. 1..... .......minutes per inch Depth of Test Pit......5 -, .t...... Depth to ground water.....'1................
'
i 1 l Test Pit No. 2..... minutes per inch Depth of Test Pit..... "�f°:`.5...-- Depth to ground water......... ....... .f". 5 ''
...........................................................
Description of_Soil.. . ?.:i. .1 ....�c?.;a��d.J } .....
........
.........................................................................................................................................................................................................
Nature of Repairs or Alterations •--•Answer when. .
applicable... ................................................................:.. ..............'........
....................................................................................................................................................
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 Compliance has been issued by the board of health.
Signed...................................................................................... ..........................
Application Approved By................................:............................................................... Date
........................................
Date
Application Disapproved for the following reasons:..............................................................
.......................................................................................................................................
_
Date
PermitNo................................................... Issued...................._.......
Date ...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......OF......... ......................................
Trrfifiratp of Tnnittliattry