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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. 79..OF......t��cTaE---------------------------------------------------------
Appliration for Dispos alark�orRepair
oustrurtinn �ernti#
Application is hereby made for a Permit to Construct ( ( ) an Individual Sewage Disposal
�n
Location -
or Lot No.
Ver Address
W.... ............
staller Address
-- Type of Building Size Lot_!;;;;t.... Sq- feett
U Dwelling — No. of Bedrooms ............................... . .Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
P4 Other fixtures ------------- --•------••-•-•--- ---
W Design Flow ............ ��'........................gallons per person per day. Total daily, flow ............. . 3a. ............. gall r s.
WSeptic Tank — Liquid capacity tt o_gallons Length ....!------ Width ._..,/.._....... Diameter ---------------- De th_...5!.._ ..
x Disposal Trench — No_/...._ ....... Width.G�----........ Total Length ---Z__$ _`_--- Total leaching area.3"-2'3 __- Y
Seepage Pit No..................... Diameter.................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( Dosing tank (
a Percolation Test Results Performed by LAI) ---
Date ---_/..c...
...
,.a Test Pit No. 1-<..-.L __minutes per inch Depth of Test Pit_, 2s.:__ `. Depth to ground wat ..___.11X...R_.
Test Pit No. 2 ----------------minutes per inch Depth of Test Pit -------------------- Depth to ground water ........................
�+----------------------------------•-----------•--•-•--•----...-•--------•--•------------------------.........................................................
0 Description ofSoil ....... ...... ...7
U ----
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•--•---------------------------------------------------------------------------------------------------
•--------------
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W---------------------------------------------------------------------------------•------•-----•-------•---••-------------------------------------------••------•------------•--•---•-•---------_.._.
VNature 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 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, d by the bo of health.
Signed/� --------------------------------
Date
Application Approved By . -_Z -- -••-------- L�� = ..,t.
' --_ - / N : Date
Application Disapproved for the following reasons:....
Date
Permit No ...... -_ _ _� .
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................t:2....OF..i�i`!1���'? r✓C................................................
�rr#ifirtt�r laf f1�.unt�r�i�tnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed k --I. or Repaired ( )
/'Jc .�
by---- -•--------•----------------•- _--=---..,,.:.--= =-=- ===--�---...-------------------•--•----------•---------------......----•------------------------------------------------.......----
Installer
at...... -'•�--•-(= ''....... 5, ------------------------------ --- ---------...-----........------•---------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction ................ dated- _/ _.._� ...._; -..Z__..._-_---..-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B STRUE® GUARANT THAT THE
SYSTEM WILL FUNCTION FACTORY.
DATE... .......----•-. InsP