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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
¢.....T..V ......... OF ......
Gru..tl.�i(!!.t+a.� ......... ....._.......
Appliration for Disposal Works Tonstrnrtiun. hrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: _ _ . , r
Location - Address
.........................
�-� ow
Installer
or Lot No.
......................................... _..............
Address a ---
491J47-14
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 ( )
Otherfix ures......................... •---•--•-•••----•-----•••-•-.-••---....•--•---------•-•-••------••••-........-•--••••--- ..._..
Design Flow ............... -c . per person per day. Total daily flow.._.....Z)..,a tai..................gallons.
Septic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width ..__. �. ...._.._..._._ Total Length__......_......... _ Total leaching area .................... sq. ft.
Seepage Pit No ........... ,�...... Diameter ... %.a.._--.... Depth below inlet .............. Total leaching area .................. sq. 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 ........................
------------
Descriptionof Soil ........... -................................................................ ----------------------------------------------------------------
-•--...-•--•---------------------------------------------•---------•---------------------•--------------------------------------------•-------------...------------------------...........
Nature of Repairs or Alterations — Answer when applicable ------- /1-0.0__-----_-_ Y-vr. .. *,-2------ �
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT%.i, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Complianc - issued by th oard
Signed. -- ----•-----------•...----------- ------
Dat
Application Approved By....------••-•.........................
-••----------••..................d/
ate
Application Disapproved for the follow' reaso s:................................................................................................................
Date
Permit No..sk-5Z-4 ................................... IssuedL. Mi/em .......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t4 ......... OF ......
fR..'E.: .. r....:. "> .....................................
(9rdifirab" of f��ant�rlittnrr
THIS hS-TO CERT-1-FV--,Thatithe Individual Sewage Disposal System constructed ( ) or Repaired
1 ;..............
by ........................ .. \c k v�-_ ; f•- .............. _ ........................----..............................._..._.
Installer
�.,a
atC t ' r .. .......... - --- ti
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 SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
/ f
'---.•_... __ t 7......-----•---------------- Inspector 'c.; - .........
DATE.....................:.::� _