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No— e 2 FEi& ............... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. 7�
. ......... OF ...... �00- ....................................
Appliration for Uhipaoal Workii Tonotrurtion ramit
Application is hereby made for a Permit to Construct (4r -or -*'Repair (
System at:
. .....................
Location - Address
---------------------
er
.........
.1c .... ..................
Installer
Type of Building
Dwelling—No. of Bedrooms ....................
) an Individual Sewage Disposal
;1/t.a70 010
............................ .... I ......................
dog,& le
* U
.. ....... oe..
Addre sloow. e1jr_
. ........................
Address
Size Lot .... 672! Sq. feet
..Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons.._._..._......._..._....... Showers ( ) — Cafeteria ( )
Otherfixtures ........................................................................................ .............................................................
Design Flow______________ 5757 . ................ gallons per person ger d d
yy. Total �IL flow__.- _------- Z..Z_0 ........... gallons.
— Liquid capacity/c9a:kallons Length ... ..... Width...`f.... ......... Diameter________________ Depth_..I IK
Septic Tank <
Disposal Trench —No . .................... Width.....__......_...... Total Length......._...._....._. Total leaching area... ................. sq. ft.
Seepage Pit No......./______-- Diameter.._.. Z ....... Depth below inlet ....... 3� . ......... Total leaching area.... *175 2..sq. ft.
Other Distribution box ( �� Dosing tank ( )
Percolation., Test Results Performed by ..... 0� r.n. __.). _C. .......... Date....- ...........
Test Pit No. l._._ �_Z-minutes per inch Depth of Test Pit.-_/2"Ce." Depth to ground water ---- ... -
Test Pit No. 2 ................minutes per inch Depth of Test Pit........._._._...... Depth to ground water.__.........___..._.._..
.............................................................................................................................................................
Description of Soil.....----- -- ---- ... - ff ..................
-- - ------- ----- ............. a,::; ---- --- . ...... .......
I
............ /. /�K'x . .... ........ ---------------------------------------
..........................................................................................................................................
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 T I TIZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha een issue by the board S
igned.... ...... ...... ..... . . ..........................
Date
Application Approved By .. .. ............. .. .. ............... I ---------------------------- ......------
Date
Application Disapproved for the following reas s: ............................................. ..................................................................
.......................... ...... ...................................................................................................................................................
Date
Permit............................................ Issued_ .......... 4t ...........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............... OF .... X *e-'- ........................................
Ae
011rdifirair of Toutpliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (_1 '®r Repaired
by....... ...............................................................................................................................
Z I Installer
at ......... 1p./ ....... ;Z ........7
..........."D—.................... --
I ---------------------------------------------------------------------------------------------
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 Permit No_______ —? f:!ZJ . •............ dated ----- 47 --- 7 .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ....................................................................................