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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... .............. OF............`i'�p>.
Appliration for Disposal Works Tonstrudion Frrntit
Application is hereby made for a Permit to Construct Q4 or Repair ( ) an Individual Sewage Disposal
a2, System at
�ft. C. �1 Qr '. X :�.___. �=� ---, ...... •••-•-----------------•---------- -- - j----•-----•-----J�--��------
n I' 2 Lorati.pp Address or Lot No. - --
1��111:16.t;, ............................................
Owner • Address
...................................................•---•---------...._._....._......----•---....----...••--------•-•............--•..........___----------•-•-•----......-••---•-••--•--•••--_..._..
Installer Address %
Type of Building Size Lot ..... �..... Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures.....-•-•---•-----------------------------------------._......-•-------------•-----•-------------•----•----•--------•----...._-•-------•----....._._..
Design Flow ............... ...................... gallons per person per lday. Total daily�flow......... 35 ........................ Ballon.
?�_
Septic Tank — Liquid capacity] -___gallons Length._v__ � ...... Width.'_ _____ Diameter ................ Depth .__.....
Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No -------- I............ Diameter ....... iG`..... Depth below inlet ..._`_.......... Total leaching areae :_'J___.sq--ft..-i!PrD
Other Distribution box (YQ Dosing tank ( ) l
Percolation Test Results Performed by._.LP-�4_.Y...P'YEL-l�r�f_Q 5 �e...................... Date..�
Test Pit No. 1. ..._minutes per inch Depth of Test Pit... �_`f .......... Depth to ground water.VcI_1e._...._..
Test Pit No. 2................minutes per inch Depth of Test Pit- -------------------- Depth to ground water ........................
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Description of Soil ........... .... 5�'.....?.LG1.a....................................
•-------------------------------------------•--....-----------•---...---------------------...-•--•------------...----•---------------•--•------••--------------••--------------.........._._......--_...
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 TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b s ed the aAqealth.,Signe ._ --------•----- •_.-------•---•
D
ApplicationApproved By------- -- - - -•--------.............................................................. ------------ -
Date
Application Disapproved for the f oll ing r axons: --•----------------------•-•--••---------------------•--•--.....----------•-------•---..._......-•---•--•-------
.................................................'....I.
.. .......... * ...... * -----------------------•--•--------------------- •------------- ••--------------------------------------- •----
------ •-------
- Date
Permit No._ ------. ../.7a--------------------••-•. Issued_-----...�� . ..V ...........
Date
- -. - _ , —
THE COMMONWEALTH OF MASSACHUSETTS17,
'r�l�I j }
BOARD OF HEALTH�;��CIO ,� 1
............. �Owi'j OF................r ': !.. ....�.�.................----.
Tntifiratr of Tontpliattrr
THIV, IS TO, C RTIFY, That the Indi i ual Sewage Disposal System constructedki
or Repaired ( )
at --------- r!L_.._...__.... ................;..3�_ In
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...... .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE. 1�..:� �'X �_..E.R�_ .�._.4.�. . __: Inspector-.' `' .M ..._ ?.'..... :
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