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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-V.'.!`- .........OF...... ��.?�.F!L?r4'. !'�"'�---------------------------------------------
Appliratiun for Disposal Works Tonstrnrtinn Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
system at: 46
... .. -
Locati - Address or Lot No.
....................... .±c'a :'"A::........................--••----__...._..._--
nerAddress
-wtits
Installer Xwjress
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms...._Z�?--------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures-----•--------------------------------------------•---...........-------------------•--------....----...--•---•---------------•....---••------••-----.
Design Flow ......... Z_ ... ...............gallons per person per day. Total daily flow---.- . Lln2-...................gallons.
Septic Tank — Liquid ca.pacityligI_.gallons Length. _l _...... Width .... :------- Diameter ................ Depth ................
Disposal Trench — No: -------- 1......... Width.. -. T.......... Total Length.......c r Total leaching area -------------------- sq. ft.
Seepage Pit No......./........... Diameter .................... Depth below inlet .................... Total leaching area ................. sq. ft.
Other Distribution box ( ) Dosing tank( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water....---.................
Descriptionof Soil ..........................................................................................................
----
W-------•---•----••----------•--------------------•--•-----------------------•---...........-----------------------•-----•------•-----•----•-----------------------.........• - -
UNature of Repairs or Alterations - Answer when applicable--- _ ZIP s )_ ....-. _.'x_47- ....
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
sbbeen
� issued by the board of h Ith.
Signed.. �_�
�: ate
ApplicationApproved By -•-••------- -- -•........................................................... ....-..._.. ..i!
to
Application Disapproved for the folio g re ons- ............... •.......................................................................................... -----
............................................S..1. r 3 z......_._..._.._....._.__.....-----..._.......--......._._.............._.........-- -:----._....... Dau..._....__.._
Permit No. .._.... -
........ _.._ Issued_ - - �1 /--------•-----
Date
/''� THE COMMONWEALTH OF MASSACHUSETTS
11-7
BOARD OF HEALTH
L9 ...... C.?.. ' :: ......... OF............ /*/* v�L, . .................................
Trrfifiratt of Tout plittnrr w 1
THIS IS TO CERT..d-F--Y_, That the Individual Sewage Disposal System constructed ( ) or Repaired (�1.
by.
Installer
has been installed in accordance with the provisions of TcI�T�yyLEof The State Sanitary
application for Disposal Works Construction Permit No -------- it ................ dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS J
SYSTEM WI FUN TION SATISFACTORY
DATE - -- ....
- 21 l�--c_•... .......................... Inspector,.
% as. descrihed ,in the
EE THAT THE