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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
LI�:...............OF........ . ........................... .......................................
Appliration for Disp al Murks Toustrurtiun rami#
Application is hereby made for a Permit to Construct ( ) or Repair (�} an Individual Sewage Disposal
System at -
....7..a--..........�__O.F:...............................••--....-•--•-------------------•---•---------•---.. ......•--...........---.......---......--
.... .............
Location - ddress or I t�No.
-- _.... ' .....--•--------•--------------•--...--------- --------- K/ --..... ....... -----............----
•- Jl�Cnes
l%�� . ----c' ..._.....�_s%8%/lllLCs
Installer Address
Type of Building Size Lot .... I/ le -I_ .7._..Sq. feet
Dwelling —No. of Bedrooms .......... :........ /........................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons-__-_--___-_______-_--__.-_- Showers ( ) — Cafeteria ( )
Otherfixtures -----------------------------------------------------------------------------------------------------------------------•--•---•-•-•-------------------
Design Flow............................................gallons per person per delay. Total daily flow ...... ......................... gallons.
Septic Tank — Liquid capacity/6,N _.gallons Length ....... 6o�'Vidth. /Q_: S.._. Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No. Diameter .......... Depth below inlet ----- /..._--- Total leaching area --- ...sq. ft.
Other Distribution box Dosing tank ( )
Percolation Test Results Performed by---------------------------------------------•--•----•••----------------- Date ........................................
Test Pit No. 1................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 ........................
------------------------------------------------------------------------•--------------------------------•••---•-------------•--------• ........
Description of Soil..........Q.. f 1_.&.�? ._. ' _.._..�5'G `S'ql----------1 .- -- Q /..------ -. .
..-----•--------..?f7v-................ -.......................................................................................................................................................
-----------------------------------------------------•---------....--•-••--------•••-....--•-•...-----------------•--------•---•---------------� ...._......._... .....
Nature of Repair or Alterations —,,-Answer when a licable...__iN��L_„__57d_ l
Agreement: A54
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has keen u�d by the,Poa f health.
Application Approved
Date
Application Disapproved for the following reasons- ------- ----------------------------------•--------------•----•-------..........---••--------•---•••••••----
..-•---•••................•-••----.........••---•--------------••........-••••.._..---------------..............•-•-•--.....--------------------------.---•---
Permit No. 3i/Sd....--••---------------------•----. Issued---....__.gl
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/.............. OF ..........
::.....................................
(Irr#ifira0 of (leant-phanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
bC7 t'�s'7l7 �T rrrNS'��°c.C'(�c/�.l
Installer
_ , _' .mac �' '`��� ; -------•---------- _
has been installed in accordance with the provisions of TrT r f The State Sanita Code s di •cr'b in the
application for Disposal Works Construction Permit No.`s `-1 � .....................
dated_- �-- .__..._......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS !, NTEE THAT THE
SYSTE WILL FUNCTION SATISFACTORY.'—
DATE.............. �............................................ Inspect�/ ........................
DATE