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THE COMMON EALTH OF MASSACHUSETTS
BOARD HEALTH
................ OF ........ ..../.-..............................................
Applirafilan for Kiopnoal Warks C onstrurtion ramit
Application is hereby made for a Permit to Construct
Systmv at:
4-58 .... �/�. ts: ntt ..�9__rr,� ..............•--•........
•-•____ Location - Address
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W �dGl e
A
Installer
) or Repair ( ) an Individual Sewage Disposal
or Lot N
....W/ YA..s
J� Ad s
Address �-77
Type of Building Size Lot ... /__.......... Sq. feet
Dwelling —No. of Bedrooms ................_ ...................... Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures -------------•-------------------- Zrj} j•---------
Design Flow .......... %ll?.. ........................gallons per �er day. Total daily flow ............ n2l�d..................... gallons.
Septic Tank — Liquid capacityJ�VQgallons Length __..__'.. Width 5A�______ Diameter________________ Depth_.
Disposal Trench— No. _____.1__________ Width ...... ...___.... Total Length ...... r.d..... Total leaching area ..... /__7tz�. ---- sq. ft.
Seepage Pit No_____________________ Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box (n) Dosing t ) ywa Percolation Test Results Performed by-..... ,1,_._1�!� Pl�._�Ge�IC .__......_.. Date__... -_________________.Test Pit No. 1__ .____minutes per inch Depth of Test Pit_.____._.____ Depth to ground er....___��r��..__.
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Description of
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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 beVissueb he oard of health.
.......................
Signed....✓c5..,.._....
Date
Application Approved By .... J12c. „11� ..............................................
Date
Application Disapproved for the following reasons_________________________________•_•-___--:-•----.._.._...__.._._.......______________________________________._
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Permit No.
�$' Issued....-- 7./_0A,. L eS' Date .....
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Date - ----•.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ... J .. .......... .....
(in of irab of Toutplianr
TPI IS TO CERTIFY, That the Individual Sewage Disposal S7stem constructed (4-1 or Repaired ( )
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\1V Installer
at•-•1-�-Q- E- =! P._-_. ---Crfcr --------------------------------.......--=------------------------ ...-----...-------------------------
has been installed in accordance with the provisions of TILF, 5 of he State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__! dated ...�jZ _U 5 ---------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
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DATE ....... •...--•..-••-•-.....-•••----••---•--
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