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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l7 ,+VA✓'...... ---OF..... . f2 i•'t: 'J'?�................
. ppliratiou for Bh4p ia1 Workii Tonstrnrtion rnmit
Application is hereby made for a Permit to Construct (Vo� or Repair ( ) an Individual Sewage Disposal
System at:
m.0 2.....D LY.c-------- .....•-_......---
I.Qaation - Address or No.
Owner ddr
................................... 4•-•-- -- --- .... -._ .............
Installer Address .�
Type of Building Size Lot --- l -_%,o. 7.7 q. feet
Dwelling —No. of Bedrooms .......... - _------------------------- Expansion Attic (!) Garbage Grinder k -j ---
Other —Type of Building _ � ...... No. of persons...._._.`�---------------- Showers ( ) —Cafeteria ( )
Otherfixtures ......................... •---------------------•-----------•-------------•--•-•----•------•----•-----••-------•------------•-....._._........_------ .
Design Flow .................. 3 ----------- gallons per person per da. Total �l�il flow ____•__--.---__ ................. gallons.
Septic Tank — Liquid capacity_l_________gallons Length. -&.'.A..'. .1 - Diameter ................ Depth-T_._R_.
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No.---_____I.______eiameter.._.._L. ._._.Depth below inlet...4.t.24._.. Total leaching area....r ..sq. ft.
Other Distribution box (iDosing tank..(
Percolation Test Results Performed by ....... .____fes.__-�'f°'_1�_ Date.. ..
...
Test Pit No. 1..,4-_�.mmutes per inch Depth of ... est Pit -_____i_..2 - Depth to ground....f
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
.................... ..•Y,-..........
Description of Soil ------•-• . !;�A'-`----------A=® 9= ':1.--. -------- -
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---•----------....-----------
Nature of Repairs or Alterations — Answer when applicable .______________________________________________.................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposald System in accordance with
the provisions of 'I` i,:7, y g g p y
5 of the State Sanitary Code —The undersigned further reel not to lace the system in
operation until a Certificate of Compliance has been issued b}_the boar health
Application Approved By..
Application Disapproved for the following teasons: _____I ............................
Permit No._�L--..--a-®
•. ----- ...... --- -�
to
to
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Date
Issued --------L-2 --'- --- • ...
- I ------
D
THE COMMONWEALTH OF MASSACHUSETTS ��� ✓Ud
BOARD OF HEALTH
%—O ✓t/ ✓
......................................... .OF .... 2 n2c ...........................................................
Tntifirtttr of Toutplianrr
T, YIS IS TO CERTIFY, That tf Individual Sewage Disposal System constructed (rr Repaired ( )
--•-•---------------------------------------------•-----------
Y ,,.............
_ r1)staller
-- -------------------------------------------•--------•-----------------------------•-----------------------------------------
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated --------------------------------- .-------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE STRUED AS A GUARANTE AT THE
SYSTEM WILL FUWCTIO SATISFACTORY.
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DATE... C�. __-�---------------------------------- Insp r_...� �