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THE COMMONWEALTH OF MASSACHUSETTS I ej
BOARD OF HEALTH
...... OF..... ..............
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Appliration for Disposal Warks Tonstrurtiun rrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (an Individual Sewage Disposal
System at:
Locati n - Addr mor Lot No.
- i.� J . ?...... - ..................................................... �.. .... ....................
n
ss
^ '
�re
Installer Address
Type of Building Size Lot_./7!2_.! S:�__Sq. feet
Dwelling —No. of Bedrooms ........ ,�?`�?. ............................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .---•--'-•----•---••------•••----•--------"---'-'•..'...............•--"'-•----------------------•-----•-•---------.-------.-.-.._--•------------
Design Flow .............. OY.!� --------------------- per person per day. Total�aily flow ......... 5.. .................. gallons.
Septic Tank —Liquid capacityllons Lengthy !�. Width. 5! Diameter. Dept!.sq
--Disposal Trench — No- ----/......_.... Width_./....._._..._ Total Length... _. K..... Total leaching area, .. ft.
Seepage Pit No ..................... Diameter ..... _.............. Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed Date ..... i zi/z � %.............
Test Pit No. 1 .... #4*f�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 ........................
........._
Description of Soil--_--------- . .................................................. ------
----------------------------------- ------------------------------------------------------------------------------ --� --�-�-- ---------------
Nature of Repairs or Alterations — Answer when applicable ............... �-,___ �• __l...... .........
Agreement:
The undersigned agrees to install the afor
the provisions of TITLE 5 of the State Sanit y Code —
operation until a Certificate of Compliance has �een issue
Application Approved By.'
Application Disapproved for the following reasons:....
Permit No .......... 90 — C)
Individual Sewage
the
Lem in accordance with
t to place the sys em in
...... ......qDe-` t)----
.............. .....................................................
.------------------------------•- ........ .........................
t 0 h Date
Issued---------------- .......(�
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
10 0 .►�- ie9 u `"' � ..........................
Trrt iratr of Toutpliattrr
TSS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by- t•-/!4 ``---•-•--- .:._._...� _*"��,- -------------•---•---•---.-------•----------------------------------•--------------------•---
Installer
at----- .... •--------------- --- la, -------_----------a.------�6 .... (• ................................................
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 ----- !2.rJs57� ............. dated -------- ft%_.=�? .=�b.---- .--. ---
.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
DATE....--- ---------------------------- --- ---. Inspector.- - --- •----- 1� -........................