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� - THE COMMONWEALTH OF MASSACHUSETTS
b BOARD OF HEALTH Zr3
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Appliratiou for Disposal Warks Toustrurtinu P.Crutit
Application is hereby made for a Permit to Construct ( X ) or Repair ( ) an Individual Sewage Disposal
System at
(� Z_ 07- 33 D -ovse 11 ILV€R `l'04 L�n.r
.... .... ......................L cats n7ddre--------------------.......------••-- ---- - --ot ...... Location -Address or Lot No.
_ E ..... i +o l r,.�-, �'`o----------------- Z3 0 �4 / 2 7 3 L�_ % s' r!hl f .............................. ----
p Owner �/ Address
a •---•------ Ae°-a-----.----------------------------------•-----------•-•--•-•.
Installer Address p^ p5,�•
d Type of Building Size Lot._ I........................Sq. feet
U Dwelling —No. of Bedrooms.__... ...... ............................. Expansion Attic ( ) Garbage Grinder ( )
P4 Other — T e of Building No. of persons___-___._____-•--_____-- Showers ( ) — Cafeteria ( )
PaOther fixtures - -----•----•-••-----•----•-•---•---•--------•---.---•-•---••---•-•--•------•--------•----------•-----------------•-----------._.......------•••.
d -•---
W � Design Flow ---_-_.--_-__-----_- -__------gallons per person per day. Total d_aily flow ...................... 3.......... galloif
ns.
1:4SepticTak—�uid capacity�QPP._galons Length -A.' Width_1_1q_ Diameter ................ Depth4'
____._
Disposal �cNo_ ..... _2_____•-_-- Width_.. /v ........... Total Len th.�4..._._.._._ Total leachin Z --sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) G /7,0 `82
Percolation Test Results Performed by-_____� 1-L-.��--------------------------------------------- Date.......--..._._...... _ __
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,4 Test Pit No. 14.. 35 2 _minutes per inch Depth of Test Pit____ S l�..__._ Depth to ground water..7A •r
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Pa'----------------------------------------•-------------...•..---------------•••--•------.....-------•.........................................................
O Description of SoilMEOe 0"f .SLiN!J 0/vVew U d" LO p�h �FUJFso iL.
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VNature of Repairs or Alterations — Answer when applicable ------------------------------------------------------------------- _................... 0........
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z 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 of health.
Signe------.... ----- j
Date
Application Approved By. . ---
Date
Application Disapproved for the f oll 2ng rea ons--------------------------------------------------------------------------------•----------•----•.._.......-----
------.
Date
PermitNo --------------------------------------------------------- Issued --------------- --------------------------------------•-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trr#ifiratr of Punt plia urr
THIS IS TO. CERTIFY_ Ahat the Individual Sewage Disposal System constructed (.'X) or Repaired ( )
by--------------------------------- ,
Istaller /Z
has been installed in accordance with the provO&s of TI rLB... 5 of The State Sanitary Code de 'bed in the
application for Disposal Works Construction Permit No --- ---___-`_-- "__f !'___ dated -------- ,/� "'—
-7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE NSTRUE® AS A GUARANTEE T T THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE -----...%.' 1 f� . �. _.....--------- Inspecto . --- . --- -• ----- - =