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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 .. 04�./V ........ OF.... M--,,r112jVjV_T1X -----------------------------------
Appliration for Disposal Works Toustrurtion Prrmit
Application is hereby made for a Permit to Construct
,§ystem at:
Location - Address
.... WAU
.................................................
Owner
.... �b_v -------------------------------------
Installer
Type of Building
Dwelling — No
Other — Type
) or Repair ( ) an Individual Sewage Disposal
............... k!��
-42 ..........
---•---•---• --------------
........... e� .....................................
V Address
....................... Ie
Address (�
.........................................
Size Lot --- ./ __o6l ..Sq. feet
. of Bedrooms -------- �3 ...............................Expansion Attic ( ) Garbage Grinder Wz�
of Building ............................ No. of persons.-.-_____-_.__-------__-__-- Showers ( ) — Cafeteria ( )
Otherfixtures ................................ ........................................................ ........ ..............................................
Design Flow.. --...__S4 ......................... gallons per person per day. Total daily flow ----------------- 1_1-0 ............... gallons.
Septic Tank—Liquid capacity/aOOgallons LengthY.`jL'.Width.VZ 'Diameter.-//'.�.--Depth.-S-.".-?
Disposal Trench — No ..................... Width_....__,.........._. Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No --------- / --------- Diameter ....... Z ......... Depth below inlet....-._._._._.. Total leaching area.,.;?P.Q ... sq. ft.
Other Distribution box (Y,5.) Dosing tank
Percolation Test Results Performed by._.... ...... SeIP& r ..................... Date......
Test Pit No. I ---____minutes per inch Depth of Test Pit ..... Zr----- Depth to ground water
Test Pit No. _....minutes per inch Depth of Test Pit --_C ......... Depth to ground water.-
...........
......................... ��:r ...................................
...................
Description of Soil ......... ,30.--- ------------_------------ 0. 71a /v ---- -------- ---
..................................... -P . ..... 42 ... ....
---------------------------------- --- ea_414ve ... 4 ......... 70 �:;Oj
Nature of Re�*irs or Alterations — Answer when applicable ------------------------------ .................................................................
................ i ......................................................................................................................................... ..............................
Agreement: _,
The undersigned 'agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
theprovisions of 'TTLE, 5 of the State Sanitary Code —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha been issued b t rd of 1, Ith*
S1
44
............
....... ................. ......
Sig e .......... ........ ............ ..........
to
ApplicationApproved By.. -'s ... ...... ........ . ............................................................... ------------- A
D e
Application Disapproved for the following reasons: ........................................................................ ---------------------------------•-•---
.----------------------
......................................
I...................... .......... ............................ ............
Permit No ....... <-g) — ( I,
. ..........................................
...................................................
Date
Issued- ........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................
0.41P./V .... OF ...... /.Z.7. ........
.......... ..
at
Qurrtif iratr of Toutpliatta
THIS IS TO CERTIFY, That. the Individual Sewage Disposal System constructed N- or Repaired
1y\
by.. --------------- ............. .....
Installer
-------------
.................. .. ------- ---------------- I -------------------•-------
at..- ------_----------_ 77, , I
iaIr
has been installed in accordance with the provisions of TITLE 5 of The State nifary Code as described in the
application for Disposal Works Construction Permit No..___ - _------------- dated___.
__ ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. —
'a
DATE &
................. �-�[02 ............................................. Inspector .... ------C -- T... ............... ...........................
...... �