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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
HEALTH
......................... .........OF ...... �/.k. . �:................---•-•----------•------.................
Appliration for Disposal Works Tonstrwtiun Jjrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (Individual Sewage Disposal
Systemat:7 0 Cf— % e c ............---•---•-------------...... ...........-------------- .........
..................... . . . ....... --------------- ---- ---- pjca.a��
wner ddress
a•--•-.VZ -.: Q ( .... •------------------------------!`. Olf1............................................
p� Installer Address
6 Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms.........................................Expansion Attic ( ) Garbage Grinder ( )
ow Other — Type of Building .................:.: ..... No. of ersons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ................ ....:... ..................••.. .
W Design Flow..........................................gallo s per perso per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid' capacity -__..._....gall s n ................ Width ................ Diameter--.------------- Depth ................
x Disposal Trench — No- -------------- ---- Wid .._......._....... Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No ..................... Di meter ... ................ epth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank )
1.4 Percolation Test Results P o ed by .................... ..................................................... Date ........................................
,0.4a 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 ........................
O---------------------------------------------••--......-----•------------------------•--------------.........................................................
Descriptionof Soil--•--------•--•-------------------•---------------------------------------------------------------•-----•--•-----................-•-------------•••......••-••---•--•••-
W•••-•------------------------------•--.............----------------...-----•-----------.....-----...----------�-7 ......------f. e .................................................
UNature of Repairs or Alterations —Answer when applicable_.... L...._...........:9'� J,l .1.........' ------------------------------
-------•.........................................•-----•-----....................---------•--...........---...........----------•---.......................-------•-•-•---......--••-•...............-•-
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 t e board f health.16
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Si--- ----- ----- ------------.................... .•--- - --••-..
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ApplicationApproved By ........................ --•••-.....••••-••---•................•-•-•--•.....•. ---•-- ... •- • -
Date
Application Disapproved for the following real s:...--•-------------------•-•--••--------------•--------•------•-------•-----•--•....._.............._...........
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Date
Permit No.8g 103Issudd.o
.._.. - .-
f g ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ........./ ..At .......................................................
(Irrtifirw of woutplittnrr
THIS IS TO CERTIF hat a In ' id ewage Disposal System constructed ( ) or Repaired (l�
bY............................................... ----- �-v -- ----ii ---------------------------------•---------•---------. .._......_._......._
at---- �- �.>!✓ 'C'`J 1 �J C !O c ........... �{y � -- �....... /--•-----------------------------------
has been installed in accordance with the provisions of T= 5 0f The State Sanitary ode, cri the
application for Disposal Works Construction Permit No. ��---------------------- dates......... .. . -0........
THE ISSUANCE OF THIS CERTIFICATESHALL NOT BE CONSTRUED ASS ,UA�iANTEE THAT THE
SYST WILL FUNCTION SATISFACTORY.
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1 DATE7D== ----------------------- Inspector 1t."----- JJ- ' ` t, ®----•---•--...--•-•-----
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