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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7. —ow ............. OF .......... V8V.J.46T.M ..............................................
Appliration for Disposal Works Tottstrwtiolt 1hrmit
Application is hereby made for a Permit to Construct (A) or Repair an Individual Sewage Disposal
System at: 1k.4-cXV 3
. _ -1 - inym... a ..F......................•--_............••----------------....._....•--- .. Z� ................ . .
Location - Address or Lot No.
••-••-----•.....__--___.....-....-•••...... ---------------------------------------- .................... ................................................. . ........ . . .....
Owner -- Address
.......... ............................................................................ ......................
Ingtalw ddress
Type of Building cl'"ee.,�kcl'CAVI? i e Lot...
gg�&? .... Sq. feet
Dwelling —No. of Bedrooms.... ........... I ...................._..Expansion Attic Garbage Grinder
Other — Type of Building ............................ No. of persons.......____.._...__..._...._ Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow.._......___ "T5 ...................... gallons per person per day. Total d,%ily flow ........... (32.0 .................. Eallons.
Septic Tank —Liquid* capacity./VPO--gallons Length ---e........ Width...47 ------- Diameter ................ D ......
Disposal Trench — No . ..... I ............. Width -...j0.......... Total Length .... A9 ....... Total leaching area ...
Seepage Pit No ..................... Diameter...._............... Depth below inlet .................... Total leaching area .................. sq.
z Other Distribution box (X) Dosing tank ( ) -
Percolation Test Results Performed by ....... /.--Q JA;EL 1A.I. ........... Date ...... ........
Test Pit No. ----minutes per inch Depth of Test Pit --- 74 ....... Depth to ground water ....7A.." .........
Test Pit No. 2 ................minutes per inch Depth of Test Pit............____._.. Depth to ground water ........................
WK ............ .........................................................
----------------------------- * ... ........... ............. . ...................
0 Description of Soil ................. --- ............................................ .................
W ...................................................................................................................................
............................................................
UW
.................................................................................................................................................................................................................
U Nature of Repairs or Alterations — Answer when applicable ...............................................................................................
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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 i s e board of healthw-,
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.... .. ... ........
t
Application Approved B}�� 00.. ... ...... . ..... ........................................ .
bate
Application Disapproved for the following reas............... ........................................................................................... ---
....................................................................................................... .................................. . -- ------------ ------- ----- -
Permit No ... a ----------------------------- - - - - Issued._ -. 2-t..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................OF...... �.&eAfLVI,& ................................................
anfifirate of (gamplinurr
IS -1_S..10 ORTIFY, That the Individual Sewage Disposal System constructed (><,) or Repaired
by-. 16CB --- OL Y 7 fz L.s ................................................................................................................................... . .. . .... .
at Installer
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has been installed in accordance with the provisions of TITLE 5 of The State Sanitary" Cpde d sc i�V the
application for Disposal Works Construction Permit No. -e-542 ...................... da ed`.',A1(M ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A A NTEE THAT THE
SYSTE"ILL FUNCTION SATISFACTORY.
DA4_1114v. --••-•----------------•----.........------......... Inspectot4r____f ............. ........ .. ...... .. ...........................