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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................... OF._ GSI
Applirtttiun for Disposal 19orks Tonst ur#ion Frrnti#
Application is hereby made for a Permit to Construct ( ) or Repair (Vj_`an Individual Sewage Disposal
system at:
.._...1...:........ v.w on: Address---------•---_• ....................
J}�.......... .Owner
_... il.�.,...5./...Y.:.---------------------------•---.._........
Installer
Type of Building
Dwelling —No. of
Other —Type of B
Other fixtl
Design Flow ....................
Septic Tank — Liquid'a
Disposal Trench — No...
Seepage Pit No ...............
Other Distribution box (
Percolation Test Results
--- ..` . ............. or Lot No.
......____--•----_----•---•-.............
.�?---�!�?.�K._.................................................................
/ tt•-.• Address
..... ..... ..... is -----------------------------------------
Address
--•-•---------•---•-------•......Address
Size Lot ............................ Sq. feet
..Expansion Attic ( ) Garbage Grinder ( )
______ No. of persons ............................ Showers ( ) — Cafeteria ( )
---------------------------------------------------------------------••---------------
allons per person per day. Total daily flow............................................gallons.
... allons Length ................ Width ................ Diameter________________ Depth ................
Wi th .................... Total Length .................... Total leaching area .................... sq. ft.
er______ ............. Depth below inlet.................... Total leaching area .................. sq. ft.
D sing tank ( )
by
Test Pit No. 1 ________________minutes per inch
Test Pit No. 2 ................ minutes per inch
Description of Soil ............................
---.....--•----•................•--•--•--------• ......_..... Date ........................................
Depth of Test Pit____________________ Depth to ground water ........................
Depth of Test Pit____________________ Depth to ground water ........................
-----------------------•---------•-•--------•---....--•----•--•-----•-••--•--------•-.....-•-••-----••-•-•-----••--------•------ .......
Nature of Repairs or Alterations — An er when a icable...�_.__[-:! .____..._..+r.d --------
.... ..........
,.�f --
..........................................................
_.__1'.I ,..) v �5- -`, i,�� '�...t_..
T. ------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issueddbb the oard of health.
--�/VD.It'e
Application Approved By- -_••--- ---------- ----•------ --------------_..... v..-.---.....
Application Disapproved for the following re S: .......... ------------------------------------------------------•-------•-_-----.. ......
.---------•--------------------------------•-•----•-••-------------•-------------•--...--•.-------------------•-•-------•--------•---_••-----.._...-q...--------------..........
Permit No ................ Q b�j ----.. Issued-------- ---- --D - ...:.4.6....................
..... Date ------
D
THE"COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... OF.. L 10. ........_�.. ` �......................................
Trr#ifirtt of Taantplittne
THIS IS TO CEM 'Y, hat e I ividual Sewage Disposal System constructed ( ) or Repaired (!K
by ................... `_,( .aiJ�..... ..... • •--.-- ...._..._...................._.
.....
Instal er
�- C1ZUt�s �U1ZCE�iNSe. �l/.d
at -----------------------------------------------------------
- W +�-------------------------------------------- ----
has been installed in accordance with the provisions of TIT F 5 of T State Sanitary Co?d� d - i ed in the
application for Disposal Works Construction Permit No .. .____.__. dated__...____° _� _ �________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A�TT
GUAR NTEE THAT THE
SYSTEM 1Al FUNCTION IWOFACTORY.
DATE _-_____...t ..... .k-- ............................................ Inspector_