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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T4.00.O.?J......... OF ........ y""9.Q.
Appliration for Phipviial ork,5 Tonitrurtion ramit
� Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
em at
o ati Ad ess or Lo No.
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� -rte - T --------•--- P...-. ` ......
pj y �6* C Address
Installer Address
Type of Building SizeLot_.l _.1�T - Sq. feet
U Dwelling —No. of Bedrooms ............ ............................. Expansion Attic ( ) Garbage Grinder �
Other — T e of Building _______________ No. of persons_______________.________ Showers — Cafeteria
aOther fixtures ......................... _............................................................................................................................
Design Flow ............ ................... gallons per person per day. Total daily flow ............ �_�___________.___.._gallons.
WSeptic Tank —Liquid capacity,!' 202gallons Length_2..'Aa�`. Width_/' �A42 ` Diameter..,//'_ "Depth_v5'�: Viz'_'.'
xDisposal Trench — No_ ____________________ Width .................... Total Length .................... Total leaching area ---------------- :... sq. ft.
Seepage Pit No ------ .l........... Diameter...... _.___._. Depth below inlet_____ ....... Total leaching area._ --- sq. ft.
Z Other Distribution box (4-1 Dosing tank ( )
'-' Percolation Test Results Performed ai--___-C el/1 : c.` hA;Date......... ��V __...
Test Pit No. L_�__oZ__minutes per inch Depth of Test Pit ... Z92_'______. Depth to ground water..�?1 .
Test Pit No. 2 ................ minutes per inch Depth of Test Pit____________________ Depth to ground water ....................
ODescription of Soil ................... ---------------•----•----------------...---•-------•-•------•---...._........--------
W ---------------------------------------------3`:/ �v s5'/31
U Nature of Repairs or Alterations — Answer when applicable ...............................................................................................
---------------------'----•--'-'-----...----------___-'-----•---•----•'-'-'-'--'----'----•...._'-'-'---'---------------''----• •_------ ------'--•-- •---'----
Agreement :
The undersigned agrees to install the aforedescribed Individual Sew ge isposal ys-tem� in accordance wi
the provisions of 'ITL 5 of the State Sanitary Code — The undersigned rther agrees not t ace th s ste in
operation until a Certificate of Compliance has been iss ed by the b rd ealth.
--- - ---- --- -----
w. s Dat
Application Approved By---- - -----•--- ' g
Date
Application Disapproved for the following reasons: -----•--------••-•-----'-------•----•-------------•-------------------------•---•---"'-----'-•----------'------
..................................................... ---•-'-•---"--'---'-----•-._...___..._...'---•----------"'------••--"-----------•-•'---'-------------•--_.__-•---------'-•---------•--•'•----'-
p Date
Permit No......................... Issued �__.� ..•-----------•-•-----
te
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... oc�'f?.:!.... OF ........ 1!,�_c?. ....._:/`.......................
Trrtifiratr of Toutplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by....................................................................................................................................................................................................
Installer
at------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLB 5 of The State Sanitary Code des shed in the
application for Disposal Works Construction Permit No-______J.,�__-__ ._________._ dated___..___.�ANTEE
I ��r �� ___.._.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE `Sf �_3 .v... Inspector ... �L_C.................................................................