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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. .................... O M,.............................------- ....................................................
Appliration for Disposal Works Cnnnstrnrtion 1krmit
Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal
System at: 3 (l f7 i 4� .....'� d I,f7 �` : /___ �[�...............
Lo do dres or Lot No.
...................... ... f-hc/--------------- -_-..-•------------------...---....--•--------
-'-•-----•------------------•----•--•---.._Address
.........................'••---'-•---•-----•---' ' ' -----•----------•-------------........... -...................................
I..K l Address
Type of Building Size Lot.... ........................ Sq. feet
Dwelling —No. of Bedrooms_ ......................................... Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ...................... -............................................ -..................... -....................................... ---..................
Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity ......... __.gallons Length________________ Width ................ Diameter ................ Depth ................
Disposal Trench —No . ____________________ Width _._. r._____________ Total Length ________._.. ___.__. Total leaching area .................... sq. ft.
Seepage Pit No ........ /_.......... Diameter_____ YO .. Depth below inlet_._:___._____... Total leaching area.................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----- ........................ -............................................ Date ........................................
Test Pit No. 1 ________________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 ............. _......
___.
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Descriptionof Soil------------------------------------------------------------------------------------------------
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 TITIL 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.
Signe----_-• .. ............ Date
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Application Approved By-------DG'i' - D
at
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
�_ a 4 / -•-•-••-Date
Permit No ..... j --d ....--------•---•--- Issued------------- 77 ��
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tntifirau of Tomptianrr
THIS IS TO CERT ,,That the Individual Sewage Disposal System constructed ( ) or Repaired
by--------------------------------------- -- ......................................... -ller _..-------._.........-----.......------------------------....._....---•••----••-••-••--'--•••-
at. ------------------------•----- 6e--------..(�p . -------------•--------------------•--------------------------------------------------
has been installed in accordance with the provisions of TIT,' if The State Sanitary Code esc ib the
application for Disposal Works Construction Permit No_____ _______ ___ _ U.______________. dated__..______._____ __'2___. �_._-_______
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FDNC ION ATISFACTORY.
DATE................. ...-� Z..2 —................................. Inspector r----------------------------- :..... - ---•----------------------------------