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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Apel ration for Dispuiittl Works Tintsirnrtion 1jertnu
Application is hereby made for a Permit to Construct ( ) or Repair (4 -)—an' Individual Sewage Disposal
System at p�^-7
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. w / Location - Address _ d _ or Lot No.
VownerAddreCs
r.._� p........c .�r1._ _e .. ........................................
Installer Address
Type of Building Size Lot ............................ Sq, feet
aDwelling —No. of Bedrooms --------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
04 Other —Type of Building ............................ No, of persons ............................ Showers ( ) — Cafeteria ( )
P4
Other fixtures -----•----------------------------------------
WDesign Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank - Liquid- ca.pacity------------gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No- -------------------- Width .................... Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No.-.------_-_----- Diameter .................... Depth below inlet .................... Total leaching area .................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
`'' Percolation Test Results Performed by....................................................................•••... Date ........................................
1.4 Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water........................
(i Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
a•--------------------------- •-----
O''`'' Description of Soil --------•--------------------------------------------•---------------------...........----------...-----....-------•-------•--•--...-------------------•---------••••...
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UNature of Repairs or Alterations - Answer when applicable._:�P�_1.617__i__Ar ----- 4151-1Di.? . �rn7�i`�.:_.�.,�Et�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIS 5 of the State Sanitary Cod h ersi ed further agree not to p a e system in
operation until a Certificate of Compliance has b is d
Application Approved By
Application Disapproved for the
Date
Permit No. g. /.:)- ---------------•--•....---------- _
Date
THE COMMONWEALTH OF .MASSACHUSETTS
BOARD OF HEALTH
.........................OF.Yt:RMOuTN..............................................
(9rrfifuttte of Tontplutnrr
H .0 T .,CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
j,
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by. _ Gni il,FE)!S?15 - -•--- •................--------------•-------._ .....
Installer
at-_ 67_...Y&P- _V.- d rJ- `� � _.Yl __---------------
---------------------------------------------------------------
has
been installed in accordance with the provisions of TITLE 5 of The State Sanitar Co as/d� cr' m the
application, #or Dis Disposal Works Construction Permit No.__ - , P6./ �- ---• dated_ .. .... .... . !......... ........
P 19- --
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A_ S A NTE THAT THE
SYSTE WI L FUNCTION SATISFACTORY
DATE... --- - 1� - ..:.. _............. Inspectc�r._r � fC'". . .. = -.....
- - --•-•-