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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... FV.;A 9.A --------..OF........ .............................
Appliratiou for Moo aiial Warks Tonstrnrttun Prrmit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at
��' • -- ���------..%�r.i�S?_�t........._.. f7 - -------------------'Y!
•-- Location - Address or IAt No.
/3 Owner PAdd
'.............. °t.lS -ZLc._._.._. ...�t.. . ..................................
Installer Address i��
Type of Building Size Lot ...._.__...��____.__..... Sq. fe t
Dwelling —No. of Bedrooms ............ 3 ........................... Expansion Attic ( ) Garbage Grinder
Other — Type of Building _..Zg:�! ............. No. of persons ........ ................ Showers ( ) — Cafeteria ( )
Otherfixtures---•--------------------------------•--.-_------------------------------------------------------------•---------------------•------•------------------
Design Flow ......... ::%.1 ..........................gallons per person per day. Total daily flow.3_. _._ ....... gallons., ,
Septic Tank — Liquid capacity!? gallons Length_ —' (e. Width A.�- --• Diameter..... ....... Depth. -S."7_0--_-
Disposal Trench — No..._----_----_--_-- Width •-• j ............... Total Length ...._._....._._. t.. Total leaching area .................... sq. ft.
Seepage Pit No .... _J............ Diameter ... %it.......... Depth below inlet --- !.LE...... Total leaching area.3— !....sq. ft.
Other Distribution box Dosingtank ( )
Percolation Test Results Perfrmed by-_. :
�__ ... .►i0 _ .�_.:� ___....._.. Date....z �'f8,
Test Pit No. 1—...._.......minutes per inch Depth of Test Pit ..... j7 _....... Depth to ground water ........................ R
Test Pit No. 2..• --._..•-_•---minutes per inch Depth of Test Pit .................... Depth to ground water ... e!!�a'�X!
..................... ........------------------•--- .........................................................
Descriptionof Soil --_-----------_--------- 43 60'.4 . ..........................•---------•--....------------•-----------.
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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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been
+ sued by the board of health. _
Signed ----- C^ vim. f C% 54PS
Application Approved By----- - - - - ....................................... ------51(ZJ
Date
Application Disapproved for the following reasons:----•--------------•--------------•----•------------•--•---•--•••-----------•----------•------------•-..........
.............................................. --........................................................................................................... ......................................
Date
Permit No --- ��:. 4 --; -3 .... Issued .......��. .r�-�.........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OHEALTH
el- �//ld�/............OF.........., °.......................................
T"Wtgfiratr jot Toutpltanrle
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (1116 or Repaired ( )
b�_..G.....-- r. -------- - --- -- -- ---------
L Installer
at--- 7' 1 -•.•--•------•--•----••-•-•----------•••-----......-•-•---------•----•-------------•-•------------
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 ----- _J_._..._.___. dated ------ .O_41 .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CQNSTRUED AS,# GUARANTEE THAT THE
SYSTEM WILL FUNCTI N ATISFACTORY. `
DATE ���.--�-------------- Inspector!5.�,,,,=......