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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�W Y1
........................................... F.....,....a,C".±m
Appliration for Disposal Works Tonstrurtion Frrmit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
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...__.
34:7
.................... --•.. ........ �_...�
ocation - Address d
....----..•........----•..............
des
Installer Address
QType of Building Size Lo _..ab.� Sq. feet
U Dwelling—No. of Bedrooms ...................................... ........Expansion Attic ( ) Garbage Grinder ( )
'k Other — T e of Building No. of persons ............................ Showers — Cafeteria
P-1 Other fixtures ............................
W Design Flow ........... ;J .........................gallons per person pet day. Total �daj low.._i.
...__. 7•�C?__________--g�lloWSeptic Tank—Liquid capacity.) .gallons, L th. ..__. Width._2__ Diameter________________ De�th_.._ ._S�Disposal Trench — No.....a? _.. Width. -.Total Length__�._ .:.Total leaching area--- •-.-•_.•.... sq-€ D
Seepage Pit No.___•________________ Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
z Other Distribution box C/,) Dosing tank ( )
Percolation Test Results Performed Y.
* tr Date... --------------•---
aTest Pit No. 1 ----- m nut s p rere inch Depth of Test Pit...�3 ...... Depth to ground water_" .......__. i
(i Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water....... ....'........z...
Description o Soil--- -�--- ,.. )----- IN ----
W---------------------------------------- ------------•--••------•----•••--•••--•-----•••-•-•-----------------•---•-•-•------------•-----•----•-----------••---•-•-----------------••----•---•-----•--•--
UNature of Repairs or Alterations — Answer when applicable............................._..______________..___..___.............._._........_..._..........
..---------•---------------------------------------•---------------•-----------------.....--------------•---•--•-------------------------------------------------------•-----------------------•--•••-••
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste in accordance with
the provisions of TITI.i, 5 of the State Sanitary The undersigned Zer a ree�ss°t t place the system in
operation until a Certificate of Compliance has ee t d hea
' U
Application Approved By ....... . ..................... .I.......... ................................
Application Disapproved for the following reasons-------------........................................................... ---.............................
.......................................................... -•-------•--------------...................---•-....------------------------•-•-•----................................................
Date
Permit No ---- `�.. S /------------------------- Issued ------------• ..------••---
Dale
THE COMMONWEALTH OF MASSACHUSETTS
by.
BOARD OF HEALTH
.......................................... OF .....................................................................................
CIn of iratr of Toutplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X or Repaired ( )
Installer
at------------------------------------------------------------------------------------------------------ -----------------------------------------------------------------------------------------------
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.___......-_ ........................... dated ------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..........51151.18.............................................. Inspector..... ��.�