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THE COMMONWEALTH OF MASSACHUSETTS
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BOARD OF HEALTH
l............. OF.............................................................
Appliration for Disposal lVarks Tonstrurtiun jjrrmi#
Application is hereby made for a Permit to Construct (�( ) or Repair ( ) an Individual Sewage Disposal
System at:
T ' ``
of
i Location - ddress 9 �+° —
.......... . jl� `:.�-'-!Pow 1'Gt .....-•-•................. .• •
Owner / �ess
nstaller Address -i7�%r ~O
Type of Building Size Lot.........�r�............ Sq. feet
Dwelling —No. of Bedrooms ........ ..............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons-----------------------_-- Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------------------------•----------•-------••-------------•------------•----------------•------------••------•-•----------
Design Flow ...........J..........................gallons per person per
day. Total �ly flow....... ---
._______.____......gallons.
Septic Tank — Liquid capacity.. ? ..gallons Length.... . !...._._ Width ................ Diameter.---............ Depth....._...._.....
Disposal Trench — No - __------------- "
------- -------- Width .................... Total Length ....... -.; ....... Total Total leaching area------ _ _.........sq. ft.
See `` e Pit No....... .... Diameter......... �Z..... Depth below inlet .................... Total leaching area.4 rJ'_L...a
Other Distribution box (k) Dosing tank ) IA%�, j • Date....02 .a/� &
..............
---------.--
.... :... �� Percolation Test Results Performed 1
Test Pit No. 1 ------- !....... minutes per inch Depth of Test Pit..... A Depth to ground water.L U1X__
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water........................
------•------------------- -------- - ---
.-----------------------
Description of Soil.....................l _... ��
•----•----------------------------------------•-•- ----------------------------------------•--•------------•---------•-----------------------...----•----
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 TITIL 5 of the State Sanitary Code — The undersigned further agrees not to place the sys em in
operation until a Certificate of Compliance has be n issued by th board of health. ��
S. - .. ...... ..---- --------------------------------------•--• ----------
Application Approved By .. . •. -- --•--- • •-••-•..... • ...............................
Date
Application Disapproved for the f ollowin e¢sons: •--------------•-----...--•••••---•...-•--•---•--•------••......-----•--••--•---•----------•---------••-•-------
--------------------•---•----•-•-------------•-•---------.......---------..............----------....---•-------•-•--•......---•-•----------.-------
Permit No.---..:! _.�C ----- Issued .
Date f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J......................
....................................
OF.............;.!11.��%..�1................
Trrtifiratr of Tomitlianre
THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed (G• or Repaired ( )
t
1nstaller
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has been installed in accordance with the provisions of TIT –E > of Th State Sanitary Code as described in the
application for Disposal Works Construction Permit No �-------Z� �------•-• dated.-... :3 ....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F ; CTION 'SATISFACTORY.
ti
DATE ............ .:.:..... 1 Inspector