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No._......0-i--Z-I/-- Fzcs....." 5..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ApplirFafiou for Diapla.sal Work,5 Toustrurtion pamit
Application is hereby made for a Permit to Construct (x) or Repair ( } an Individual Sewage Disposal
System at:
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L c tion -14
Address or Lot No.
.....................
Addres
e---•-•-=---•---�u/� G - -------------•--------•------•----•--•--•-
-......__
a
Installer Address
d Type of Building Size Lot__ f_FO7_'�__------ Sq. feet
Dwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons____________________________ Showers — Cafeteria
Otherfixtures-----•-------------------------------------------------•-•••-----•-•--•--•••----••-••--.............................................................
Design Flow ..... __________________________'�___gallons per person der day. Total daily flow ...................... 2U v ........... gallons.
WSeptic Tank — Liquid' capacityla d_.gallons Lengthe__`:� `�___ Width_4_._ `v_ r Diameter________________ Depth_g_( = 4g _.
x Disposal Trench — No_ ____________________ Width .................... Total Length .................... Total leaching area __._____________.._sq. ft.
Seepage Pit No._____/------------ Diameten-Ce_1:>:_[_1---- Depth below inlet________________ Total leaching area --- 2o. _----- sq. ft.
Z Other Distribution box (4 ) Dosing tank ( ) z
`~ Percolation Test Results Performed by___)2weF1Ts................................................ Date______f________ __.____ ______..__.__..
,4 Test Pit No. 1,4_EVZminutes per inch Depth of Test Pit___f _ ______ Depth to ground water__. VP__.�!�r�
Test Pit No. 2 ................ minutes per inch Depth of Test Pit____________________ Depth to ground water ........................
W----------•-----------------------------•--------------------------------------...-----...--•------- .........................................................
O Description of Soil ------- �'L-_L1� .---nt OlUr-r TQ-_-• < E-_-•ej !/�----UNDLCR Z�.. �O�vYI /9f71d
x.... a � � 1----------------------------------------------------------------•-----------------------------------------------------------------------------------------
--------------------------------------------------•---------------------------------------•-----------------------------------------------------------------•-------.-----------------------------------
Nature of Repairs or Alterations — Answer when applicable ................................................................................................
-------•--------------------•--------------•---------------------•-----•--••-••--•--•-........ ................. •--•••-----••------•------•-•-----••-•--•••---••--•-•---•----•--•-•---•-•-----••-•-
Agreement:
The undersigned agrees to install the afore cribed Individual wa Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary de —The undersine rther grees not to place the system in
p Compliance has be I ued b he bo lth. F�
operation until a Certificate of Com ned____ ______________ _-_`..:.. ---------------------------------__________ �.`���
_. .__._____ �Y.
Application Approved By___
r �' a
e
Application Disapprove or the llowing ons:------•------••••••--•--•------------....................................................... ••-----•-•--•--•-
---•••••----•----•--••--•--•----•-•--••----••---••-•--•-•----•-•---...•-•----•••-------••------••-••••------•-•-•------••--•--•------------••-----•-------------•-•-•-•••--- ----•--•--•••----•------
Date
Permit No... 3 L ----------•---=---------------------- Issued D G r� L_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. ............ OF ...... .......:.. ...................._....._.._.__.__•__
fit
05atifiratr of �vrm�r�i�tatrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (—)_or Repaired ( )
J
by -= -------------------------------------•-----...---------------------------------------------•------------------------•--•---------....----•--------------...._
Installer
at'............................................-----------------------------------------------------------------------------------•-•-------------------------------------•--------.----•-
has been installed in accordance with the provisions of TIT" 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No _7 = .._____.. 40 . ............... dated___ .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �-
DATE.................................. ---........--------•--•--••----------•-••---- Inspector-=-�-`---- --