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No . FES........ ........
' Y THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- �AJ �ft�-Nicau
..-..... OF ..................................... �
Appliration for Disp.aiial Works Towitrnrtion Prrmit
Application is hereby made for a Permit to Construct O') or Repair ( ) an Individual Sewage Disposal
System at: _ ,p
....... ------- -- O?" -- �--------------- . �� `/'
- .. o tion - Ad s or Lot No
.. .
ownt ess
Installer Address
Type of Building Size Lot ............................ Sq. feet
U Dwelling —No. of Bedrooms_ ..........................Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
a Other fixtures -----------•-------------------------------•--
W Design Flow ..._._... r5: . ... ....................... gallons per person per day. Total daily flow........ . a.. --_-•-------.•_-.__-_gallons.
- i
WSeptic Tank — Liquid capac>tyLdQ Ogallons Length____ 43...._. Width ------- Diameter ................ Depth --- 4........
Disposal Trench — No. --__---_---------- Width .................... Total Length .................... Total leaching area -.---.--------------sq. ft.
Seepage Pit No -------- I_.......... Diameter-____ ���. Depth below inlet ......4 Total leaching area.5�i, b.
Z Other Distribution box QC) Dosing tank (
'-' Percolation Test Results Performed by.................. e _ __. E.L C E/_e..l h� ..:t Date...%'_Z_7.." 8.�-._....
Test Pit No. 1 ... �:_.a''____minutes per inch Depth of Test Pit....���j_ Depth to ground water_. btu""
(i Test Pit No. 2..<..�Z..minutes per inch Depth of Test Pit --- Depth to ground water' ...c)
Descriptionof Soil ---------------`s ... ------ .....................................
--------------------------------------------------------------------------------------------•--•---------••--••••--------------••------••••----•-------•-•----•-------------•------•-----...---------•-
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 TIT1Z- 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the rd of health.
Signed-., -------------------------- •--•--------------........_
Application Approved BY - --- ..-•------ .. ..... ... .....•-..._-•--�-.............................. --------�-:��- _
Date
Application Disapproved for the following reasons:---•---••-----••-•--------•-------------••------••-•---•-----•---•--------•-------••------•-•--•--•--•----------
Permit No........ ------------------
Date
Issued ---------- R
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................ /..CGS::..✓.......OF.... ,~':...,...:.r::y................. .......................
f�rr���irtt#r of (�unt�rli�anrr
TH.�IS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (.-or Repaired ( )
b42:x. ... ......................................................................................................................................................................
� Installer
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..y? S: ___ :!.;i.'.._.__---__. dated ----- V_ -ZZ --- S�u .................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE... a .1�...._
.............................................. Inspector ------ -----
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