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THE COMMONWEALTH OF MASSACHUSETTS �nL
�OARD OFHEALTH
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.�•.................OF......Vz41CM-4!V�I.CT . ........................
Appliratinn for Disposal Warks Tonstrudiun 1hrnti#
Application is hereby made for a Permit to Construct (j4 or Repair ( ) an Individual Sewage Disposal
System at:
::......._�� �i✓l _---�--------------
Loca ' Ad r ss
Owner��
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Installer
Type of Building
............... c .!g5 tI 6 +_-----------
............... e!�,1.3jt-l)zl C ...nl2u.c:7
- ress
....
Address dd q
Size Lot -in.. �i.._.1..............S .feet
Dwelling —No. of Bedrooms ----------_--- ---------------------Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons--------..---------_------ Showers ( ) — Cafeteria ( )
Otherfixtures---------------------------------------•--......------.------------------.-------------------------------- .._...
.....Z.4�..._..------_......gallons.
Design Flow ................ U-0 ....�.gallons per person�e} ay. Total daily flow-_----. ................ Depth .... •.Septic Tank — Liquid'capacity�.gallonsLength..:._.. Width_.(D. Diameter
._.
Disposal Trench — No- -------------------- Width ... ._._........._. Total Length_--------._._. j... Total leaching area .................... sq. ft.
Seepage Pit No ............. /...... Diameter ....... /Z-.... Depth below inlet .... Total leaching area.- 6. .... sq. ft.
Other Distribution box (tj) Dosing tank
Percolation Test Resul�s� Performed by .......... t�_ 3:--------•.•.-t-��� - 0 Date .........
Test Pit No. 1................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 ........................
Description of Soil �_ P.�.... j
................. Z(60 ....... /fes a__. At
•.....-•----------------------------------------------•--------------------------------._...-----------------------------------------------------...--•---------------------------........-----•----•-.
Nature of Repairs or Alterations — Answer when applicable.-----------------------------------------------------------------------------------------------
----•--•-------------------------------------------------------•----------------•---.......------------..._..-------------------------------•-------...------........_....---......---.....•---•-------.
Agreement: '
The undersigned agrees to install the aforedescribed Individual Sewage Disp& l System in accordance with
the provisions of AITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bbepa issueobepboar of health.--- �` . �-��/�'C_— .......... ....e-
SignedApplication Approved By.... A.,kZ2 ',M 1i����----------------•-----•-------------------------------•----....
Date
Application Disapproved for the following reasons:---•--------------------•-------•-------•-------------•---•-----------•---------------------•------------------
•-------------------•---------...----•------.....--------------------------------..........----•-......------------------....-----------•------------GG----+----•---------.._..- -Date -------------
Permit No ---- `c....Z" t .. --- Issued.....-6/ZJ_ 1.. ...............................J�
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................... _T .................OF...!.................................................................................
4 Tntifiratt of Tompliaurle
THIS IS TO ERTIFY, That the Individual Sewage Disposal System constructed (b-"*) or Repaired ( )
by...... 1.-:+�... N_ r U 0 - ----- ----•- --------------- ----------------------
I tall
------- - -Install
has been installed in accordance with the provisions of -TITh 5 of The State Sanitary Code as described In the
application for Disposal Works Construction Permit No.._ _____________ dated._- :'_1. ..__
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY �
DATE... .............. l.t .� 1 .................... ........................ Inspector....._