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No ..... 1172e?
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/...0..�/ oF..._..... tf �l"`-.-(_:� 1 C�c " k .-------------...............
Appliration for 19isposal orko Tilustrnlrtioit remit
Application is hereby made for a Permit to Construct (i/) or Repair ( ) an Individual Sewage Disposal
ystem at: n
... G,! :/l� f% .---• - - •-ate -��- -- ' -•� ... ..............
_ ............. -
L c ion -Address r Lo o.
Owner A ress
............... ter•---•-•-----•_____._....._._.__._.._ QA. .. ___-•----___...__. ---
Installer Ad ess
Type of Building Size Lot._ �j . � Sq. feet
Dwelling —No. of Bedrooms____________________ _______________________Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures _____________________________________
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Design Flow ............ 116-2. .................... gallons Per P_er dday.Total da,i�Y
flow .................
...__ gallons.
Septic Tank — Liquid capacity -/.-.o gallons Len -e--�__Width__./.7jQ. Diameter ................ Depth-- 4..
Disposal Trench — No. ......./ .......... Width ...... /JQ._,..... Total Length ......
Total leaching area-. ... ft.
Seepage Pit No -_-------------_- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box (414- Dos' n nk ( )
' 4b-e.---�' f� .1 c ..... Date.. - is
Percolation Test Results Performed by_______ _______ ____ ___ - /i.�C : _
Test Pit No. 1_ _____minutes per inch Depth of Test Pit ... Aw�_ Depth to ground water ----- �1_......
Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
,a
iptipn of Soil---- G--
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Nature 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 T111 LE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bq&ajss9fd by the boarAof health. _
Application Approved By...
Application Disapproved for the following reasons:
:;^at -e -- - --------
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Date
Permit No.----• .............. I .................................
-------------.._. Issued------- ------ .
THE COMMONWEALTH OF MASSACHUSETTS
/ BOARD OF HEALTH
.......................................... OF ............. ........................................................................
Tatifiratr of Tontphaurr
THIS..IS+TO CERTIFY; That the Indi >dual Sewage Disposal System constructed O or Repaired ( )
b--------------- ------------------ ! - -------------------•--------•-•-------•------------------------------- _-------------
i Installer
at------------ -- ............................... ___ --• --------------------------------
has been installed in accordance with the provisions of TITIN-- 5 of The State Sanitary Code �s de4ribed in the
application for Disposal Works Construction Permit No .............. 1'l,: _____-:=_ ` ' �__ :__
------- dated-----------'--�--- � - �----': -1-----•---------
THE ISSUJ NCE OF THIS CERTIFICATE SHALL NOT E
CONSTRU S A GUARANTEE THAT THE
SYSTEM fL FUN ION SATISFACTORY. tor....
. .......................................... Inspec---•------- --•--•--_•---- -•-----•-