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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF ..........................................................................................
Applira ion for Disposal Works Tono rurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
....... .3 .....-n.f11.! ....5 ..'._.. �r.?h���. of�r-.----•--------------------------------------------------------------------------------------
-.-Loca '' n - Ad ss -•-• or Lot No.
44 -•...........
Owner Address
---•--�.... - -Q ............................. •--------------- ..------............................................- •--...__....._..
...
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms...........44.411, ..................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building RAR. U' ....:........... No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures...-----•-•--•----------------------------------------...--...------••----------------.....---------•------------- - ,---•------------.------------
Design Flow ............. .12A --------------------- gallons per person per day. Total daily flow ................ Z. 47,45 .................. gallons.
Septic Tank —Liquid capacity..teV41gallons Length ................ Width ................ Diameter................ Depth................
Disposal Trench — No...... . ............ Width___: ............ Total Length....3v 1---.---- Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area ..... ?:....... sq. ft.
Other Distribution box (X ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. I................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........................
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Description of Soil--------------------------------------------------------------------
-------•-•----------------------------------------------------------••--•-----------------••------------------•------•------------------------------...-----•----....-----------
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 ' ed b the board of health.
Signed,_.._. i----- 14 -------•--•.............'_.......-•---•------... .......................... _....
//D
Application Approved By...C ............................................... ....... icJ.l. - 5--------•
Date
Application Disapproved for the following reasons: ..............................................................................................................
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Permit No.-- .._7i�Qj.._._._. Issued-........1�-± a
-•�------•-----..nu......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................ T ............ OF...................................................................................
Trriifiratr of Tompliaurr
'HIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed � ') or Repaired ( )
- -
..........................................................
by ....: . :...................•----------------•-•----------•-••....------------........_.
Installer
at------.... ---k- - ................................ ......................................................................................................................
has been installed in accordance with the provisions of TITR 5 of The State Sanitary. Code., as described in the
application for Disposal Works Construction Permit ,iV'o ✓.:._.............. dated-_ `_..'.... .a.._..._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE
f (.� _. Inspector... r Y
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