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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
WR' ...............OF.......... w!!... ................................................
Appliratiou for Disposal Works Toustrurttun Fermi#
Application is hereby made for a Permit to Construct * or Repair ( )Q an Individual Sewage Disposal
System at:
LftSj.F ...............................
�/� N �C Location - Address
�A
-----------------------------------------
Owner
Owner
--- --'- "-.--`'E= v ��_ ---
Installer
...•' or Lo� .............................................
__ .. Lyl�b _)?!1 ✓
.........................................
Address
Address
Type of Building�J Size Lot.... � O, ��O-------Sq. feet
Dwelling — No. of Bedrooms .__......_ 4............................Expansion Attic ( ) Garbage Grinder ( }�
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ..................................
Design Flow .......... t1 ------- ------------------gallons per �er day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' capacity.i .gallons `Length_W.-O'i_.. Width..6'`-0 1.. Diameter ................ Depth.41_10!..
Disposal Trench — No. ...... I............. Width ... . 1j .............. Total Length .... 7.fa_____._._ Total leaching area___1U0_0 ----- ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................. .. Total leaching area .................. sq. ft.
Other Distribution box (/) Dosing tank ( )
Percolation Test Results Performed by ------ LjO94D.... US5. ... .`. �+1=-_..�N r-.......... Date ........ 7=11.A.0--------------
Test Pit No. 1.. L- -.....minutes per inch Depth of Test Pit ----- fo.o........ Depth to ground water ----- �->rvim--.......
Test Pit No. 2 ... LZ..minutes per inch Depth of Test Pit......_2.Z..... Depth to ground water ....tej%l----____ t
4 �1�� -- z- ................... `....�..--------------------------•..........-- -- . .
Description of Soil-------------- (;2=18 --- h2 .�?fh�Y. S ?------------------------.4,.-2 . ... M = Sf1 t2---------------------------
----...---•--------•---------------••-•.._.18-.---3Q.... 3 ....._!ra------------------x-16...--E--oow..5i� .......--------
Q- ® - _ <SE n =---------------------0 .... ---- 5
Nature of Repairs or Alterations — Answer when applicable .................. -_-__ --- h-: -00 ..... ..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ii TE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by e bo d of health.
Si ed ------------
2 Date .
Application Approved By. - :�� ` �Q -
`-
Date
Application Disapproved for the following reasons-.......................................................
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--------------------------•---•-------•-------------•--------------------------------•-•--------•-------------------------.._._...------------•----••- •--------- ----••------------•-------•---•----
Q ..-------Date ------
Permit 1Vo. 41 I57 -----------------------
Issued-_- ---
Permit �Z
Date /
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................: `.................... OF .........`...............`..........................................................
(Irr#ifirat a of Toutpli anrr
THIS IS TO CERTIFY, T Individual Se ge Disposal System constructed ( ) or Repaired WIr
Installer
ll��.��at•---•------•-... .f-�tc,I-.-4j=�`-
has �
been installed in accordance with the provisions of TIe State Sanitary C e as de• in the
application for Disposal Works Construction Permit No....0....._.._... dated___.. "_.. T .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A4UARANTEE THAT THE
SYSTEM L F�CTIOrTISFACTORY. 6
DA-------�--------------------------------- Inspector----- 'azzf . •----•------..
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