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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. OF ........ ..._.ir_.�..fi.�'�_.._ex...............................
...
Appliration for Diap.aiial Warks Tomitrnrtiun Prrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System t :-- .�
..ti...._ �.�.... � � �� � � � P� 1 �
D
77
/ �a ion - A� s or Lot No.%
l ...�
Ow �6r Address
j .....
-----•-----------n Installer
Address T
Type of Building Size Lot lio...!V41 Sq. feet
Dwelling — No. of Bedrooms..-----. �'7..............................Expansion Attic 0/� Garbage Grinder Xv
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
OtherfiNture-----------•-----------------------•--------------......------....---------------------...------------ ;- --- -
Design Flow............................................gallons per person per day. Total daily flow............_. .... _._..._..-gallons.
Septic Tank — Liquid capacity/L)VO.gallons LengthPAI ..... Width --- 6 ... _..... Diameter ................ Depth ........ 46 ... ..
Disposal Trench — No ..................... Width .................... Total Length..............! .... Total leaching area..... ;.._......._.._sq. ft.
.� _.. Diameter .._._--__._. Deptl below inlet ...... lk... ........ Total leaching area..f_ a /...sq. ft.
Seepage Pit No_________ _______
Other Distribution box (�) Dosing tax 9
Percolation Test Results Performed by..___.�: 4 ..:?'=.2: ...........
......... Date .... � ___._
Test Pit No. 1 _____...... minutes per inch Depth of Test Pi ... .......... Depth to ground water.._ ............
Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water ........................
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_.
Description of Soil ............. xw r�cz. .-------- ------------------------------------........----...--•-------........---•-•......
..........................................................•._._.._..........._..._._.........-----------------------------------...--------------------••------------------•----------------•-•---------
•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
UNature 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 iITIE 5 of the State Sanitary Code — The undersigne ier agrees not to place the system in
operation until a Certificate of Compliance has been ' ed y the boar f healt
Signe = -•---- - . a
------------•---- -----OD
-- --- -------
at
Application Approved By ....... A--.--....................••-•-•-••-----•-......---•---•----... �� e
Application Disapproved for the following rksons: __ j ....... .---------------------------------------------- ......._---------------------
.-------•••--•.................•-•------•--•-----------------•-------•-----.....----------.---•-----------•----•----------....-•-•-----•---•-••-------•--...--•---•. ••-•-•••------.
Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................ OF ...................................................................................
Trrtifiratr of Toutpliatta
THIS IS TO CjjRTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
at•----•------.. .... ....... -• •• ....... • «2`
has been installed in accordance wi the provisions of TITLE: 5 of The State Sanitary Code/as de-cribed in the
application for Disposal Works Construction Permit No..14-11 �............. dated-_.._�1�`�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector----------------....-----------------------------