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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
As!o!;!?� ... OF ........ y .. . ............................................
Appliration for Disposal Works Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct or Repair ( 4 -r -an Individual Sewage Disposal
System at: ro, —I L5
........... ...................... . ... .. ....... . .
LocatiGrIA.&ddr ss or Lot No.
to Q
.......... . ve—mew1m ......... 15f_—,Ma.LkA9V ........................... --------------------------------------------------
Own-- Address
'n
.......... C-... � e -. A v.%. AO. ---------------------- ...................................................................................................
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 ...................................................................................................... 3�� ......................................
Design Flow_._.._.......-. - ---------------- gallons per person pe.
Total daily flow ......... -0 ...................gallons.
Septic Tank LLiquid ca citLength...._ff ...... Width .... re ........ Diameter ................ Depth ................
y I&D -
Disposal Trench — No. Width ...... S .......... Total Length..._ rz. ...... Total leaching area.L.Ifft;1q. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. I ................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___.........__..........
.................................................................................................... .........................................................
0 Description of Soil ........................................................................................................................................................................
W
r% .........................................................................................................................................................................................................
.................................................................................................................................... (� ..............................................................
—Answer when applicable .... ;;M6T�A� .... ...... N '5;! ....
Nature of Repairs or Alterations . .......... ---------- * ---- -----------
io a-,---------- r
. ----------------------------------------•--
Agreement :
..........................................Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T 1E 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has
lzbeen issued by t board of iealth.
� z_�
Application Approved By________________ --
Application Disapproved for the f 6wing reasons.
Permit No ...... ._./ .q...1
......................
1
0 -..Y
....... ............................. .......o/... -X.
_7 .....
.. .....
.. ......
Date
.............................................................................................
......................................................... ...... / .........................
Issued -------------- --- .......... ... U ... A ------------
za�tte
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... OF ...... ........................... ........
(9rdifirab of T-nutplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
by.......................... ......................................................................................
f6staller .
at------------------(a-to------- ............................ ; .....................................................
has been installed in accordance with the provisions of TLITLI; 5 of TJie State Sanitary Code as described in the
application for Disposal Works Construction Permit No__& Jj___q__j ------------- dated ..... G-2,0_!fn -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THJ�i
SYSTEM WILL FUNCTION SATISFACTORY.
.1 t__