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No.�.--------- Fims................� ...
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THE COMMONWEALTH OF MASSACHUSETTS �/
BOARD O� �F,+c� HEALTH
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u1.tJ....----- -- OF ------------- T"f �..t��M C .....-----------...----------
Appliratiuu for Disposal ?darks Cnuustrurtiou Frrutit
Application is hereby made for a Permit to Construct (�<) or Repair ( ) an Individual Sewage Disposal
System at:
..4:. &ZG E, o..N...'_1 mei.... . �!✓y..--------
Location - Address
-fG --•------------------------
Owne
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Installer
Type of Building
_n om ...............
Address
4.............................................
Address
Size Lot....r..... ZS_. ----- Sq. feet
Dwelling —No. of Bedrooms ............. - .......................... Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No, of persons__--_---_..-_--.-_-_--___- Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------•-----•---------------•---------•----------•---------- -----------------------------------••------------
Design Flow ............. ..a'7. ----.-----.------_--_gallons per person per day. Total daily flow -___-__.-._-.Z_2___-. -___.gallons.
Septic Tank — Liquid capacity_/P06_gallons Length ..._._.___ Width...._—.,,4 Diameter ................ Depth _.'.......
Disposal Trench — No. --___------------- Width .................... Total Length........._ ..._..... Total leaching area_... ---------------- sq. ft.
Seepage Pit No ...... I............ Diameter.__.4 4t.�_ �. Depth below inlet.......... Total leaching
Other Distribution box (><) Dosing tank (
Percolation Test Results Performed by ---- ..:_. _____._�-t-Z`'..lR_ Date:�l__.%__'_�_�-.__...
Test Pit No. 1-- '...minutes per inch Depth of Test Pit_./._s3.7.-"____ Depth to ground water_!W%-_.6.7
Test Pit No. 2 ----------------minutes per inch Depth of Test Pit .... ................ Depth to ground water___...................
Description of Soil ........ ��^ A 1 _!A
................................................................................................................................... .
Nature of Repairs or Alterations — Answer when applicable________________----------------
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Agreement:
_______________
-.-•-----------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sy9tem in accordance with
the provisions of TITI:j 5 of the State Sanitary Code — The undersigned further agr4not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed------------------•-----•---------•---••-------•------------------•--•------------ -----------
ate
Application Approved By-- -- .- ...----•-----------------•------••------------------•------------- ate
Application Disapproved for the following asons:----_-----......................... ----------•------------------------------------------------------------
....--------•-•---------------------------------•----------------------•------------------••------------...--------------------------------•-------------------•.-•---- •-•-------------•---...
�j- ------_---Date
Permit No. - - Issued ....... �S_- . ------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. OF .....................................................................................
Trrtifiratr of Tlautpliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at------------------------------------------------------------------------------------------------------------------------------------------------------------- --•---------------------------------•-•-
has been installed in accordance with the provisions of TI T IE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_________________ ___________________-- dated ... .------ .-------------------------------------
7
THE
__.____ ---__..__._---.--_-----.----
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT Blr STREDD—AS A GUARANTE HAT THE
SYSTEM WILL F10 � SATISFACTORY. 'J �
DATE.................................. ..................•--- Inspec ..................................