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App-Permit-Compliance
4 3.3.e ��y T F�s...r'� 5 ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH mpP (9- ..................... .................. _0 F ....................... ........ ........................ •.................................. Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: Loc tion . Addre t or Lot No. Owner Address W Installer Address UType of Building Size Lot .............Sq. feet Dwelling — No. of Bedrooms --------- Z- ............................Expansion Attic ( ) Garbage Grinder ( ) '4 Other — T e of Building No. of persons____________________________ Showers — Cafeteria PaOther fixtures--------------------------------------------------------•-------•-•---•--. ---•-----•-----••--------•-----•---••-------------------------------...•--- d W Design Flow ........... 5.5 ............. ......gallons per person per day. Total daily flow ......... __...Z- _Z- I=> WSeptic Tank — Liquid' capacity�.,�C�Z, kallons Length_ .. Width --- _/--___--___ Diameter---------------- Depth... ........ Disposal Trench — No ..................... Width _._..._._.. ____._.. Total Length .................... Total leaching area .................... Sq. ft. Seepage Pit No -------- /_._._...... Diameter../iD.t..�`.._... Depth below inlet_ �s__�?_._'_--- Total leaching area.Z �'_ � sq. ft. Z Other Distribution box ( .. Dosing tank ( ) a"Z �' 9A0 '-' Percolation Test Results Performed by ...... � -!o,_._.S� Z r ................... Date.._ 1.......s ,l_.....-_.. Test Pit No. 1. .._ 2minutes per inch Depth of Test Pith ._ ... Depth to groun water.....�de4 Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ P4---•-----•-•--•-•--------------•--------•---•-------•-•--•-•-----•--•----•----•-•------.....-----.-- ......................................................... 0 Description of Soil------... .------�,r� tft4c ©------ !4 ----------------------------------------------------------------- x V-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W----------------------------- ----•-------------------------------------•--•------•--•--••-------------------------------------•--------------------------•-•••----•-•--•-•-------•-----.....--------- UNature 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 TITIN 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu by thg board of health. Signed•-- ....... -- - -46---- �--------------------- Date Application Approved B �'t ------l ------ Date Date Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------•----...... ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-' Date Permit No.--- .-, .2.2 ........................... Issued ............ ..---..... /' -/ --k Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f�rr#ll#rtt#rf f��atrlirtrr .............. THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (Xor Repaired ( ) Y------....... ; S':. .'.._._:... Installer at-------- . . e, ---------- ---------------------------------------------------------------------------------------------------------------------- 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 --------- �___ .g'�'•�._--__ dated_.-._____ ��__=:! � - ��'>._._.-_.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 1. -2;v= 7•,�lG ri r j{ -:J DATE ............ f�f�',�i 4-L-2 - Inspector_�:s--- <'c, t:4 .....: rye-`- ( r,.i . i-:: %i_ .. i•(...+i s4�h�t_...