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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... .............. ----.-............OF ..........................................................................................
Apel ration for Dispasal Works Tonotrndiun 1jrrntit
Application is hereby made for a Permit to Construct ( ) or Repair (�--j an Individual Sewage Disposal
System at:
1. `'.._..s1 e.�J..... .� AlS
Location - Address or Lot No.
Own . ............ Address
.......................... �.��---------------------•---.. .......--------------._.._..........-------....._...
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ..................• -•-.-•------.-----.......Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ---------------------------------------------------- *
Flow -------------------------------------------- gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' ca.pacity............gallons Length .............•.. Width ................ Diameter................ Depth ................
Disposal Trench — No - -------------------- Width .................... Total Length .................... 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. 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........................
Descriptionof Soil --------------------------------------------------------------------------------------
-------------------•-----------...-----•---------------------------••---•----------------------------------------•--
Nature of Repairs or Alterations — Answer when applicable.... lC.. l -.. _:..�.'% _....._ ..�..�.......................
----------------------------•--------•-----•-------------------.....---.......---------------------------------•-•--•---.------------------------------------------------------------...__...__---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 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 board o
heal .
Signe%%-_.�.r..,��- `--
Application A .-------•------------•----------------------------------------------------•--•-----.---•...................D............-_....
Approved By -
Date
Application Disapproved for the following reasons:---•-------------•------------------------•------•-•----------.-------------------------------------------..._
...............•--------•----•------------•---------------------------•-------------------------------.......-----------------------•..........------•------------------•--------...----•-•--..._.------
Date
PermitNo ................................................... ...._. Issued. ..................................................... ..
Date
THE COMMONWEALTH' OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ............................................... .... ....................
(Intift ate of ToutplianC
THIS 1 0 CFp-3IFY,'Thr the Individual Sew ,ge Disposal System, constructed ( ) or Repaired
- J / !%�.e.1.,. �.� ....._.... -------------------------------------------
_-------.-.
Installer
. ........ - ------ - -------- ------------------------------ --
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary CZ., a descr' ed in e
application for Disposal Works Construction Permit No.Zj _ -P2 ........... dated......- �� ... �.S............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GAN• EE THAT THE
SYSTEMA WILL FU CTION SATISFACTORY ,
p ,---
DATE..................... (✓� 1 -.................................P �r ti
Inspector 1 . --------..................................................