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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-----------------OF..........)!7Ae ----------------------------------
App iration for Disposal Works Tnnstrnrtiun ramit
Application is hereby made for a Permit to Construct N or Repair ( ) an Individual Sewage Disposal
System at:
3 _ k- OOP ...... ' .. .Ute-- ------------------------------ ..........-�°-
Location - Address or Lot No.
------------------------------ ...t 5�.... l.y..G�1FF%t No ........
Ll Owner �` L! CIL, Address s i
Installer Address
Type of Building Size Lot....... � --1� �----Sq. feet
Dwelling —No. of Bedrooms...................._._.._._.___.._........_Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ........................... No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----•--•--••-----------------------•---------------......--------...••---•---------------•-••-----------------••---------...._........---------------
Design Flow ................. ::;:T.................... gallons per person per day. Total daily flow.......... . ®.__................gallons.
Septic Tank — Liquid capacit}(.(?.O.O-.gallons Length...-...... Width._. ........ Diameter ................ Depth ..4___------
Disposal Trench — No- -------------------- Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ....... /_........... Diameter -__ Depth below inlet ..... 4.......... Total leaching area4! _s4..sgrf--G.r..P,
Other Distribution box (>G) Dosing tank ( )
Percolation Test Results Performed by. _4�?'410-__ --.!^ L ` ___ .....•.. Date... ............
Test Pit No. 1. C_ ..._minutes per inch Depth of Test Pit.,/.I --------- Depth to ground waterJQ.4?T___��.__..y
s
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water.A___-a _.................
--------•---------------------- �,� q
Description of Soil �'�=�� %� ..................................... ...................................
-------------------------------••----------•----------- -----•---------------•-------------------•••-------------------------------------------------------•----•---------------------
Nature of Repairs or Alterations — Answer when applicable......................_..........................__...._......_...............
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 unders' further agrees not to place the system in
operation until a Certificate of Compliance has been issued t b health.
Signed--------- ..... .............................. ......
Date
Application Approved BY ------------------------------------
--- - ------- s.S^=�2
Date
Application Disapproved for the following reasons-------------------------••----------------------------•---------------------------------------------•-...------
---------------------•------------------•-------.....----------•-----------------------------------------.-----------•------------------ ---•------------------------------------------------------------
-Date
Permit No.__.... lg.I............................. Issued _....... 5..5 ... 6 ............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1� t< .... .OF.... ...........................................
Trrtiliratr of T-amplianrle
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (_--f"Or Repaired ( )
b ,� C, "'� _�-,: Wil.
- -------------------------------- -------------
Y------ - ----- Installer •-•--------------------------------•---------•--------------•---------•------------------------
-
at
----------------------- ---
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__.
S — �y `�' dated---:: �
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTf LIED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIOP.SATISFACTORY.
DATE.......... . -- Z-7-------------------•------------ Inspecto -- -------- ........................................................... -----•--.