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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'1 .............0 F....�/lA!1i . .................__...........
, pphration for Disposal Works Tonstnution Vrrmit
Anvlication is hereby made for a Permit to Construct
System at:
Location - Address
........ f 1 ---- ---- ------------------------------------------
Owner
Installer
Type of Building
) or Repair (>Q an Individual Sewage Disposal
.......--•--------------------1-- .1 ..��........_t M. P.. - ......•
or Lot No.
..VSs :_.. a��:...tr1.�..._...../�.....,.���?�1.? ..........
Address
Address
Size_.Sq. feet
Dwelling — No. of Bedrooms ............. .._.. .......... Expansion Attic ( ) Garbage Grinder ( )
Other — Te of Building ..
Other—Type g ...__.d......._. No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures...............•----...........-----------•----------........------....-----••-----------...----...---..........------...---•-...•---..._.
Design Flow .................. ....---......--..gallons per person per day. Total daily flow ........._ .. 3�---R6..................... gallons.
Septic Tank — Liquld ' capacity,4�5Z ---gallons Length._/O Width:._ Ck' --------- Diameter ................ Depth-_ ...
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ......... ------ Diameter ........ -.t._........ Depth below inlet...f ............. 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........................
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•............
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Description of Soil ............. =/..--- -.. 5�-------- - 1 _`_.:_.. 'Jf-�Q_...s 1d......--•................
-------------------••-•---....---•------------•------•---------•••------•-•-•-•---•-----............-------•.......------------...-•----•-------------------•---•-------......._..........--•---.....---
-•-•-----------------------------------•-------.........-•-•-----------------------------------------------------------------------•--•-----...---....------------•-----•------•--.....---•-•...........
Nature of Repairs or Alterations — Answer when applicable.,ep�_O& -----G" zS ...... - -1 ....
W- ,,�..._.--:ZaA21. ----- ....... .... 4 ...... zy"..Z---r-- ........ .............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been,,i§su O by the 4parsl of health.
Application Approved
Application Disapproved for the following
1" e
------..�... Date
......--•-----'Permit No .......... � O-- - a �-----------------------•-----------�---•-•---------------Issued.�a�.. ..._. ...... ��.= l V
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
h................ o F:........ .................................................................
Tertif itaof (aomphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
'-
by---------------•----------._.T------G-----2?L?L------.....-------•------•------•----------......-----------..•....................-
-
Installer
at�-------------------•---------...--•----•----------......--------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as describe(Lin the
application for Disposal Works Construction Permit No ------- In— _?1_�------------- dated--......--. .---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEu*-WILL FUNCTION
DATE. FUNCT ON SATISFACTORY.
..4r�vUq......-------•-------•--•----
-..... Inspecto^r --.-................•-----............................
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