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No.� ----------------�-•- FES......._.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF......V-ri
. . .........._...._.__...................
Appliration for Disposal Works Tonstrur#iun Frrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (+% an Individual Sewage Disposal
System at: --
............................................- •-• ..........._..---.
LOT- �5....t1r44�—�3
/i A /) Locartion .Add ss A/ or Lot N.
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. l ................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----------------------------------------------------------------------------------------------------------
-------------••--•-------------------•-----......--•------------•---------•---•-•-------------------•----•-••------.-------- ----------- ---
Nature Pf Rep4irs or Alterations — Answer whenplicabl ,cG�-Q-�. -
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disp,o4l tem in accordance with
the provisions of TITIZ 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 t oof lth.
Signe-- Ad --- .----------------------------------------- ----�-
Application Approved By ......
.----------------------------------------- •--
Date
Application Disapproved for treasons-.............................................................................................................. ..
/,, .Date
Permit No._gQ. ...'.r�-------------------•---------------- Issu .... ------_/2%. D� /-----------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H''E��A''LttTH
....... ....... OF ...... .t .....................................
(9rdifirtt .. l of Tomptianrr
THIS IS TO ERT-IF,Y, Thate Individ al Sewage D'sposal System constructed
by ----------------------------
�.. t
has been installed in accordance with the provisions of TAT 5 of The State Sanitary
application for Disposal Works Construction Permit No.. .__ __ _' ................. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS�
SYSTEI�A�dVI�LFCT ONATISFACTORY.DAT I(.. a. ............................................ Inspectors . .!2.. -
or Repaired (a
as�lgyif� i� the
{) / t-------------------
iANTEE THAT THE