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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_ ...................O F .........................................
p iratiou for Dispoiial Works Towitrurtion Vamit
I Application is hereby made for a Permit to Construct ( ) or Repair (k, } an Individual Sewage Disposal
System at: ,
... ......... W1 MfflilM .......
..................../Y ---.....L at n - Addrs or Lot No.
44J
r Address
Installer Address
Type of Building Size Lot ---------------_--------.-Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------ ---------------------------------..----------------------------------------------------_--------
Design Flow............................................gallons per person per day. Total daily flow -------------------------------------------- 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 ------------------------------------------------------------------------------------
.................... --------- •--------------_-------------------------------------------------------..-..--------- ---------------------
of Repairs or Alterations — Answer when applicable.. �r---------.:-T..` .. _._ _-_.. ...... -_ a
----------------------------•------------------------------------------------� �i__l.. )-----d---� /0-17 ---- t�Jc1 �.�T ��� .Q�_ �.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'TTL y g g P Y
5 of the State Sanitary Code —The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed --------------------------------------------
ApplicationApproved By -----------------------------------------------------------------------------
Application Disapproved for the following reasons: ..................................
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PermitNo---------------------------------------------------------
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Date
----------------- -'--------------------------......------
Date
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Date
Issued----------------------------------------------------•---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .............................................................. ......................
Trtifira r of Tompliam
THIS.IS-TO )CERTIFY hat the Individual Sewage Disposal System constructed ( ) or Repaired (�)
GC/ / 1 -------------------------------------------------
at.....----- . ---..1- ---------- 11-----1J_- e --------- C_A` ` ----
has been installed i accordance with the provisions of TITLE
application for Disposal Works Construction Permit No..........--�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT
SYSTEM WILL FUJ)�f}'CT�QION,SFACTORY.
T
n A ii / Tn -
-------------- -------
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Sanitary Code TEE des ibed in the
dated--.... ---1V ---z -U ------------
E® A GUJ RANAT THE