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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................... OF...Y9.R)M.®gTff................................................
Appliration for Mipag al Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
6 System at:
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Location - Addr ss
.. c �2..s ��2'1 sj ^r - _ ®._ _.....2 x ........1 1 . _..1 ........ . ... ...........
Owner - Address
Installer Address
Type of Building 2 Size Lot_l.`� !.�kl ------Sq. feet
Dwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building .............. -------_---- No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures..--•--------------------------------------------------•-----•-------------•-• ••----•-----••-----------•--•-...._......_...._....--------.....------
Design Flow ....................... ss�--------gallons per person per day. Total daily flow __............_....%73-.Q........... gallons.
i c'
Septic Tank — Liquid' capac>ty/00 __gallons Length8_—'.&'_.. h�__.._.. Widt�'f?_.e _.._. Diameter________________ Depth__
_ ..'.
Disposal Trench — No. -_--••-•-.._-•-•-- Width f......... ......... Total Length ................... Total leaching area --_-------......sq. ft.
Seepage Pit No ------- 1-_.-_______ Diameter. -C.- Depth below inlet •---'4._.......... Total leaching areaz.d..sq. ft.
Other Distribution box (`x) Dosin tank ( 11
Percolation Test Results Performed by..&W5J :'rJ. _ k1�eres ���!Q .. 7�
_ Date_ -- ........
Test Pit No.-fl.2 .minutes per inch Depth of Test Pit.. J.449. "__.. Depth to ground water ... z z;�...`._.......
Test Pit No. 2----_-_----- minutes per inch Depth of Test Pit .................... Depth to ground water ........................
•--------------------------------------------------------------------------......-- .........................................................
Description of Soil ---.4-R.—Y... UIVAK.......-rL-�l� «I�% Citi N � '-----------
........................................................
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 TME 5 of the State Sanitary Code — The undersigned furt er agrees not to place the system in
operation until a Certificate of Compliance has been issu by t ar of iea . q
Siged ............. •--•- . • .-------..... - - - ------------•--------_-----• --- - .......�1...._
at
Application Approved By-----'-' ��'�<tXlL...._.�
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------- ---•-•-•....-•-----••----•---•----•••----•--••--••-----------••---•--•-------------
Date
PermitNo --------------------------------------------------------- Issued ......................... .........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................i.�...OF..........�...:................................
(9rdifirtt#le of TontpHattrr
THIS IS TO C"TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----.--- / g -I t,V 17----------------------------------------------------------------------
--------------------------- ---
..-
nstaller ....... r
has been installed in accordance with the provisions of TIT�I , 5 of Th State Sanitary e as�de cr>be�, iy he
P ,fl
application for Disposal Works Construction Permit No ------ ___.._. _-_--_- dated._.��_� � .f.1.._..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector