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THE COMMONWEALTH OF MASSACHUSETTS
i'
BOARD OF HEALTH
10W 1J
............ OF ..................................... ........... .........................................
Appliratiun for Bispuuttl Works Tonstrudiurc 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
Systml at: _
�...��.......�A1 M Ni.�., 'FC? { ... I ... !� �..... ..... d _�...................-........................ _......_..__._..
Loc�tion - Address or Lot No.
-- :.�l-.......: -1-a.m tA...................._.. .. - � 4�. K ? N
Owner Address
a - ._....__.........
...... .......................... ...... q; .......
Installer Address
ppqq T of Building Size Lot_____.. S feet
U
Type g f------•-------- -
Dwelling — No. of Bedrooms .............. ......._........_.....Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
p' Other fixtures
Design Flow ..................... ........... gallons per person per day. Total daily flow ............. 5` ® ............... gallons.
W W Septic Tank —Liquid capacity.1D00..gallons Length.5.1-k_4
__ Width -44'.—U." Diameter ................ Depth..5.J-8'r
x Disposal Trench — No. ........... t........ Width ..... 1 Z ......... Total Length .._..Z -A.'_...... Total leaching area __7036 ----- sq. ft.
3 Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank( ) { ING � Z z', A 79
Percolation Test Results Performed bP..t�lke'�...:..__�.4L1.1SK....... Date........ 1. - c.
Test Pit No. I...... Z%....minutes per Inch Depth of Test Pit ........ _Zrrl... Depth to ground water_.-hl�?N_�_ir.......
Test Pit No. 2 ....... Z.__ -_minutes per inch Depth of Test Pit .............. Depth to ground water ....... �i7li..........
a `....................... f--•-^_.... .......-----------._._.._...----••--......... ..........._.............
O Description of Soil. k..... ..�._l.4?.�.'.... L.Q. _A. '.S � i.i..... ��?.�l — . ��_... E l_!�:Cl. - i✓
U.............. .... ..................t_....._
w1'n�ul ��'��''� -----------------•-•--......._...._.........-------••-----------•-----•---.._.._......_..
Ux Nature of Repairs or Alterations — Ans er when a lI ble.
P - _SS_ PPS : -t ..... :... n .......................... 4 ----__-__---_______________----------------
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 hall been issued by the board of health.
Application Approved By
Application Disapproved for the
D....... \
........1._ -Date .......
...............Permit No .... .------- �•-----------_......................_ ............._.....-Issued..---------..l.�L� .........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
j. W10 ......................... OF ....... YtlKp- 0-1,11h}................................................
Trr#ifutttr of fauutphunr
HIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed;'( )'or Repaired O
.......................... --...............................................................................................
•••--•......
_---------------
------
Q Installer
A Ttt----_...-
has been installed in accordance with the provisions of T of The State Sanitar ode as descr� In the
application for Disposal Works Construction Permit No .. . ...... . ........................ dated ,:,._'_�-,____..__.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU ANTEE THAT THE
SYSTELAAA,NILL FUNCTION SATISFACTORY. -------- % ---
DATE-�f�a---------•.......................... Inspector....... '� � a .? . /�6.'... . $ :` .............................. '