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No.iLl .1FEB
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................0 F .... Y..490.,,0VrY1.!.......................-_.....--..-.......-......._.
Application for Diopoottl Works Tonotrurtion 11amit
Application is hereby made for a Permit to
System at
.33 ...... P�u . S a ki. sfr�sl,
Qr - ioa��-yAddress
owner
Q%.. =..1.'----•-• ................•.........
• Installer
Construct ( 1�-Kor Repair ( ) an Individual Sewage Disposal
----
Lot No,�.
Add s r GG
Address
Type of Building Size Lot .... �✓j.� V Sq. feet
Dwelling —No. of Bedrooms___... C.�.aa
................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures...............................•----._........_...._.....:._._..----•-------••---....••-----.._.._.._..-•-•-•---••---•----_____•-------.........._....
Design Flow................5 ................... gallons per person pel day. Total daily flow ....... . ......__...______:_____. l�v
Septic Tank — Liquid capacity/-�I/%__.gallons Length./__V1 6._.. Width___ .' __ Diameter ................ Depth.. :__...--
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area_..6_3;;.?,._..sq. ft.
Seepage Pit No ..................... lameter.................... Depth below inlet,................ Total 711chV'ng area.___.__..1�..,.y:sq ft.
Other Distribution box ( ve Dosin nk ( ) ���•• 4X4 �Q�I2yS lRZ brae Si/X� �h
Percolation Test Results Performed by..1111.1�Q4 .}° .../�........... Date..�,1�8.�_.....�.i..
Test Pit No. 1.:<.2 minutes per inch Depth of Testkit____ s ._ Depth to ground water.._..,C
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
......................... Y ......._..._..._........._•-••-•----•-..........---...................--•--•-----
Descri tion of Soil---..._...��y%1,�.�1f!...1!�Y'!�I1tt "v.._rOl-..__... ......._..
'p ........ _....
----------------------------------------------------------------------------------------------------------------------------- ----................................
__ _____---
Nature of Repairs or Alterations — Answer when applicable..____ii_ �'
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 undersigned further agrees not to place the system in
operation until a Certificate of Complianc has be�!/ ued b�ythe brd of health.
to/ck
Application Approved Byw. -'--f!
Application Disapproved for the f ollouring reasons:
by
Permit No ...V " &2 ....... . .... . .................... Issued—t—,...... 7. l X1. 9.... Date ......
nate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. ,°......, .... OF....{.::�r:i.`............................................................
T erfif uttti of Tomplionre
THIS IS TO CERTIFY,
lual Sewage Disposal System constructed
I
Installer
or Repaired ('`)
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.. ,.1 ___:r . ..................... dated......,r..
.1 _.:::.._.� ._r .......-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ :_:................. :............•---•----••...•••••-___----•--•-••
Inspector....,; ______............... ............... ................................