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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............./............. OF__ ..........
Appliration for Dispaa ial Works Towitrurtion Frrutit
Application is hereby made for a Permit to Construct K or Repair ( ) an Individual Sewage Disposal
System at:
Location - Address �j
...t................ Lt.. u �...L..1..t�.� 1°rl� .. t ... �� �
k- -= ,�
T Owner Address At
A/A,
0
Installer Address
Type of Building Size Lot./_0_.y..?_��.Sq. feet :'
Dwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria
Other fixtures
Design Flow ............... 5�..................... gallons per person per day. Total daily flow........... !t�_a.0................. gallons.
Septic Tank — Liquid' capacity/a -O..%allons Length.... ��..'Width__._ I ._`.._. Diameter ................ Depth ... '..____
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No._-O-ff__---- I.... Diameter ---- /Pr.67'Depth below inlet------- -- - ----- Total leaching area�t`�--_./...1Aq-4t. 6,P, D,
Other Distribution box (DC) Dosing tank ( )
Percolation Test Results Performed b L� GU -O.._r�L L E l NVQ Date r®-_ `. ��
Test Pit No. 1...._minutes per inch Depth of Test Pit.. ��" Depth to ground water/ -1.5' 7
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water. .......................
.......... --....
-----
Description of Soil ............. f ��...'
.............................................. •..............••----•---•-•-----•---•-•------•-•-•--•••••--••---•••-•-•••....---•------•-•••-----•••-•-••-----••---•••-••-•-•--•-••------•...----------••
------------------------------------------------------------------------------------------------------------------------------------------------------------------••----------- ......................
Nature of Repairs or Alterations — Answer when applicable...................................................................._............._._._._.....__.
--------------------------•----•---••---•••--••--•--•---•-••--•-•••--••-•••-•--•--•-•----....---•-----•--••---••--••----•---------•-•-----•-..........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual ge Disposal System in accordance with
the provisions of Ti 5 of the State Sanitar — The nder gn rther agrees not to place the system in
operation until a Certificate of Compliance l� been issue b t o r alth.
Signed............ •-•-- ................. --------------------
I Date
Application Approved By-- • •• •.... -- .. •• -•-- ----••................................ --•---!
Date
Application Disapproved for the following reasons: --•--••---------••---••--•-•--•-•••----•••••--------••••------•--•-•--•••--•----•••-•---•---•---••--------••----
•-----•--......---•-•--------••--••-••-••••----•----•-•-----•-------...••--•--•••---------•-----••-•---•-••---------•-•••••--••---••-----•---•-•--------•••-----•-•-----•-•-•-------------•-•••--.......
Date
Permit No.--- •--------------------•--• Issued--------/
Date
THE COMMONWEALTH OF MASSACHUSETTSy4e"jt--1'
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BOARD OF HEALTH a4;
................J• e 's' .....OF...�IIX?0°,✓Grl%i.........................................
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TH;,S IS TO CERTIFY, That the Individual Sewage__Disposal System constructed ( or Repai ( )
by-••-•••------- ........ -------------------------------------------- ---•-----------------------------•-----•------------------
Installer
at
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 --- 2a-•_. i cS=�_..__-_..•... dated ----- •..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ....... =-•�LZ ............................................. Inspector ...... �1_ �s �Z '=