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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J�
................ OF..... j�1 %< i C�!.r/...........................................
Appliration for Dioposal Works Tonstrudion 1rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( – aniIndividual Sewage Disposal
System at
ocation • Address
Owne
Installer
Type of Building
Dwelling — No
Other — Type
ds'
Ma..........-•............................................
or LotNo
...... O 7 ----........................................
......•.....................................
.. dress
CP
Address
Size Lot ............................ Sn. feet
of Bedrooms ............... ....................... Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------•--•--------------.--•----•---------•---------------•--•.............-----•------•--•-------••----------•---.----•
Design Flow ............. _.______._...._...gallons per person per day. Total daily flow ....... 3 -----------------.._gallons.
Septic Tank — Liquid' capacity............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. 1................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--------------------------------------------------------------------------------------------------
---------------------------•...-•----------•---••--•---...-•--•-•--------•--•...•-----•-•-•---•----••-----•------•----•-•------•-•
----------------------------------------------------•----------------------•---•---........-•--------...•...----------------------•------•-•----•------- t------........��.....----- --.....
Nature Repairs or Alterations—Answer when ap licable._--.f _.S_''� �.......�.__4�-�•---'-.--•-----_-�-.....•..
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitar ode — he undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ern iss by the b�cct� of.healtle
Application Approved By,
Application Disapproved for t'heljolloz jyhg reasons: ....................
Permit No .... �.K..-----•----
e
��..a'.
Date
.-----------•----------------------------•......-----------•-•------.-••--
Date
ISSued..............lD)a {. _.._...
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(inr#ifiratr of Tompliatta
THIS IS TO CERTLFY, That the Individual Sewage Disposal System' constructed ( ) or Repaired ( L}•
Lby ........ .N ............... //j� .......-----------------•--...------•-•--.......------------...............--•--.............--•-
L/, Instal er
has been installed in accordance with the provisions of TITLIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ----------------------------------------- dated ................... _.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUES S TEE THAT �-
AT THE
SYSTE,MIWFUNCTION SATISFACTORY.
DATE............................ �i�% ..................... Inspecto.... .. .......... .... ......................