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THE COMMONWEALTH OF MASSACHUSETTS
BOA
RD`!OF HEALTH
-l�o...iN._......OF....:.7..(IAcVVgwvt�+---------------------------------------------
Appliration for Disposal Murks Toustrurflun 1rruti#
Application is hereby made for a Permit to Construct ( ) or Repair ( 1..Yan Individual Sewage Disposal
System at:
............ .__$ 14 ..M ...... 0 ......................... ............"""•� � . n ........
.----rMM \ Location - Address c ` ,� _ ,,-�. or Lot No. n
........... �.1 l�.l�::.....�.r5.�.�1h!_�� �:.._._.. ^- ' '-.........................5.�.V ---)( � ......................�
Owner _ Address
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ...... 9...............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building .......................... No. f persons ............................ Showers ( ) — Cafeteria ( )
_-
--------................
---------------------------
Design Flow........ x.�..........I...............gall s
Septic Tank -- Liquid ' capacity..10 allon
Disposal Trench — No. 3:�.. Width.....
Seepage Pit No ..................... Diameter ................
Other Distribution box ( ) Dosing
Percolation Test Results Performed by......
Test Pit No. I................minutes per inch
Test Pit No. 2................minutes per inch
Description of Soil ............................
---------------------------------------------------------------------------------------------------------•--
,er n er day. Total daily flow............................gallons.
Igth ... ......... Width.. -LC...---- Diameter---------------- Depth ................
..... Total ngth-----�.�..._ Total leaching area....................sq. ft.
depth below i et .................... Total leaching area .................. sq. ft.
----------------------------------------•--•------------•-----•--... Date ........................................
Depth of Test Pit .................... Depth to ground water ........................
Depth of Test Pit .................... Depth to ground water........................
--------------------------------------------------------------------------------•------------------•------------•-•-•.
----------- ---
Nature of Repairs—orr�Alterations — Answer when applicable ...•_ —_ CrS _. ��! -5 .... ...........
Agree-'--v.-.----•------_---.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 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 hpa4h.
Sign�d� z` .- ................. "x ' n `i..... -c.
Application Approved By_... ".............. !
Date .....
Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------••-.-------------------
.........- -------------•--- -
q 25 8 laky
Permit No.............................L ...... Issued..... D i- ...�......._....�
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�......... OF ...... \.J.!� i .,?�.D.V7tS �. .........................................
Trrtif iraV of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (t_4/1
by ....................... ----------------
.......
...........
...
.........
=--........---•---•--?................................................................
at.. tea. ......AA ` .... `.... -'�----_Installer 1.d.. _ .1_Ve.-F...............................•-
^'
has been installed in accordance with the provisions of TITLE 5 of Thetate Sanitary Code a descr'bed in the
application for Disposal Works Construction Permit No.-- � ---.. dated __.... Z�:e..1.8.2.........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS ARANTEE THAT THE
SYSTEM ILL FUN TION SATISFACTORY. -- �
DATE...........{.L-�a 1Aw �. Inspect
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