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Nom. �••--- ak Fns..I s.°.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.------..OF.......�'!a'rQ'1�(:e• •
,� lirtt i�an
for Roposal Worko (Ionotrnrtian Prruat
Application is hereby made for a Permit to Construct ( ) or Repair ( y1 an Individual Sewage Disposal
System at: T— 3 MAP ---43
t9 v�sds oar,. S ------------- �o---...--�--�-------Lot---•----•-----•- ... .......
................_.... - . _....... •--•--...-----•--
Location - Address
So....±?.... ...
----------• y Address
O'- Z ecs �l tst �,D.�C14:V1 C.t 1 f�E! O .4 S
�---- ----
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 -----------------------------------•-------•----------------------------------------------------------------------------------------------------------
Design Flow-------------------------------------------- gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No- -------------------- Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ---------- I--------- Diameter..... ..... Depth below inlet. -A ............. Total leaching area --- ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by---------------------------------------------------------------------------
Date
Test Pit No. 1................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 ........................
Description of Soil------------------------
-------------------------------------------------------------------------------------------------------
Nature of Repairs or Alterations—Answer when applicable.D.__�c2__-!'---�!
Agreement:
The undersigned agrees to install the afored ribed Individu Se age Disposal System in accordance with
the provisions of TITL i, 5 of the State Sanitary de — The uncle ig d further agrees not to place the system in
operation until a Certificate of Compliance ha i u� the d o f� /��
Application Approved By ......
Application Disapproved for the following reaso'is: ............
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PermitNo.--- -------•--•----------- ----------------------------
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Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........7 0 ........... OF..... .............................................................................
(�irrtifir of Toutpltanrr
THIS IS TO CERTIFY, Th a the Individual Sewage Disposal System constructed ( ) or Repaired (X )
--••--.
by "
Installer
------------------- ------------- ..... ----------• ......---
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 ----------------------------------------- dated_--..____-_-_- -..___._.__--._-----------------
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector