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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ......... .................... OF ........ I., .... I ................................................................... ......
Appliration for Dispaual Works Tomitrurtion ramit
Application is hereby made for a Permit to Construct
System at:
..........................................
Location - Address
_..!__L 2A.M.' ..........................................
Owner
...... 40_4A ..............................................................
Installer
144
P4
Z
0
x
U
U
Type of Building
) or Repair ( ) an Individual Sewage Disposal
.... . ........ --------
.... j
or Lot No
L,
Y..
y 4 &
..............
.... 44de, d Vr ss..
.... A
. ................
Address
Size Lot.._._.....Sq. feet
Dwelling —No. of Bedrooms ......... %3 .............................. Expansion Attic (NO) Garbage Grinder QVc)
Other — Type of Building ............................ No. of persons.....__......_._._._........ Showers Cafeteria
Other fixtures .........................................................................................................---------------------------------------------
..... ** --------- * ---------------------------
Design Flow --------- ....................... gallons per person Ver day. Total daily flow ........... J10 ..................... gallons.
Septic Tank—Liquid capacity-/0-0.0..gallons Length.Z.-A ----- Diameter_____ - — ----- Depth. -4: "A."_
Disposal Trench — No..._. .. . .......... Width_._..._ ....... Total Length ...... . .......... Total leaching area ---- — - _-_____sq. ft.
Seepage Pit No ---- OAP . ...... Diameter._14!v ........ Depth below inlet --- 7g - - -------- Total leaching area ... 2iCZ --- sq. ft.
Other Distribution box (Jej Dosing
Percolation Test Results Performed by.._ ................. Date .... ...........
Test Pit No.21L .... 2 -.-minutes per inch Depth of Test Pit.......f f .. i ...... Depth to ground water____________________
Test Pit No. I ---------------- minutes per inch Depth of Test Pit ...... /.,? . ....... Depth to ground water ---
................17....... --- -
DescriptionofSoil ...........6......4........./&.-.7 . -.
.............. .....-2-.-;, -"---
.-.-. ------- * - - --.-.-.-... -.-.-.-.-.-...-.-
................. I - -----r - ........................................................... ...................................................
-------------------- ...................................................................................................................................................................................
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 TITLE 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 the board of health. I
Application Approved B;
Application Disapproved
............................................
Permit No.. -.S-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............................OF...... .........................................................
Tntifiratr of TOUtphatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by....... ..............................................................................Installer ............................ . ...........................................................................
..................... I ........ .............. ---------- --------------------------------------------------------------------------------------------------------------------
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 CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE._.. .................. I ..................................................... Inspector ...... ---------- m ..................................... 7� .............