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ASSESSORS MAP N0: 33 4716
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No,;.t1.�.'" 3aJ...... PARCEL NO: % Fss.......�•�................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® E HEALTH
................ OF...... .. .... .........-----------••-.---..-------------
Appliratiou for Dispo at Vork�i Tomtrurtinn frrmff
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
• ..... --- ...................• .._......_._..
Cf
Locatio Address Q
.._..... — _.. ........ .... Y . or Lo .......-. ...... . ..........
-- ... --
.Address
. Owner -••
-- ..---•••------------------•------ ..
Installer Address
Type of Building Size Lot..Z4f_4-F'?.... Sq. feet
Dwelling — No. of Bedrooms ............ A............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures---------------------------------------------------------•----•---------------•-•--------••--------•---•-----•••-------••......•-•--•-•.....----------
Design Flow ............................... S ----- gallons per person per day. Total daily flow ...... 3!1.0 .......................... gallons.
Septic Tank — Liquld' capacity_ ZS;0d_gallons Length___t®"_ '°_ Width__ _________ Diameter__-_-_- Depth.-!;.-_______.
Disposal Trench — No ..................... Width ...... Total Length................._.. Total leaching area .................... sq. ft.
Seepage Pit No .......... ,l....... Diameter.._... Al-__---_- Depth below inlet .....4.......... Total leaching area..944 7__...sq. ft.
Other Distribution box (✓) Dosing tank ( )
Percolation Test Results Performed by. �'._Ousi._CA!?4..... .&Y� 'IM4........... Date.... '_l.Z .___ -------_---
Test Pit No. 14W....minutes per inch Depth of Test Pit ---- Z. '..... Depth to ground water. .i✓e.e*......
Test Pit No. 2 ----------------minutes per inch Depth of Test Pit .................... Depth to ground water ........................
-•----. -----.....--•------------------•------•---------••-•-•---------------------------------------------------------------
Description of Soil - ---------� r i�r/rn......-.'4-'-e�-------------------------------------------------------------------
---•-•-•-•-•••----• •---••-•-----•-.....•••-----------------••---------.........-•---••-----------••••-----•-----------•----•---------•---------...•-••--•-------•----------•.....••-•-----------------..
--------------------•-------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------...---•--
Nature 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 TIT, I.i 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been sued by the board of healt .
...................... D
D
Application Approved B��tA�/,D�at�e
-----------
Application
Application Disapproved for the following reasons:
-----•-•-----•----•-----------------------------------------------------------------------.--------------•-----------------------------------------------------------------------------
Permit No .y. ------------------------------------
- - Issu Date
Date
7 ®--•-
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
LOM%A) ........................ OF..........................................................
AT
Tntifiratr of Toutpliatty
.THIS IS TOBRTkFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by.. d?7.�C.... r-----------------------------------------•----------------------------------------------...-----------------------------............
A A ... tem J $ r _ / ._ Installer
has been installed in accordance with the provisions of T TLE 5 of The State Sanitary C sde. sfe�s 'b m the
application for Disposal Works Construction Permit No. ....�9�---------------------• dated,,. 1 __ -++-` --
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS-" NTEE THAT THE
SYSTE W L FUNCTION SATISFACTORY.
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