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THE COMMONWEALTH OF MASSACHUSETTS
.1BOARD OF HEALTH
Appliratilan for Dispasal Works Tonstrnrtiun 1rrntit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
system at I
cation -
.............� L. L�. o�ress..............._.._..._.._.._._._._ - ...._. or Lot No .......................... «.... «.«.....
.. ••--•-•..
Own ...._Address
.�p��i► NS1l...........................................
Installer Address
Type of Building �( Size Lot Z4:��_�..Sq. feet
Dwelling — No. of Bedrooms ............... ......................... Expansion Attic ( ) Garbage Grinder V)
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other lixtures _--------••---------•-- .. • -- --- •-
_. • __________________•••------•-------__ ---
Design Flow ........... ( ...............gallons per perr day. Total dailyow_...._._...Q..x.l.!.S.... lor,
Septic Tank — Liquid' capacity.1�gallons Length_T...0.. Width:�t,__4-_._. Diameter ................ Depth_ `►__..
Disposal Trench — No ..................... Width .................... Total Length ...... r Total leaching area. sq. ft.
Seepage Pit No ------- I........... Diameter...... 1.4 ...... Depth below inlet .... �...�... Total leaching are yK.__...sq. ft.
Other Distribution box(j�) Dosing tank
Percolation Test Results" _� Performed by....../- .............................. Date... .. �......_.. ...
Test Pit No. 1... � -minutes per inch Depth of Test Pit... . _ ..._. Depth to ground ater.AJCWC,-.__..
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water........................
---••--••--.....��_.._.. b. u--- ---- ..
. ..........................
Description of Soil .....OLn...3 0 ----- JW T._�.� ...... �._.. � �' ���[ L1r 1 1 f �...................
..............................••------•--------•------•--............-----•---........------•------•-•---•--............-----.......-•-------••-•--------.......---....._.._..._.................._-•-_..
.._.....--•---•--•---•--•---------------------•-----._......_._......._.....----------•---••--•----• ••--•-----------•-----•----..._._........-•---•---•-----......-•-•----••••-••-••••••-•--••..........
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 TITLZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h en iss ed by hoar h.
Application Approved
Application Disapprove
1 Date
Q� � qpp
Permit No..Q0 ___-____________________________________ Issued- _ ...CO' o S�
Date ............. ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
!� ......... . OF ....Y
9
Crrrif utttr of faantrinnrr
e—THIS IS TQ.CERTIFY, That the Individual Sewage Disposal System, constructed OO or Repaired ( )
Installer
athTX1`art v t�I f ►vE (4 �:�f__.1�! 40 .. , ...:.
has been installed in accordance with the provisions of T - -J The State Sanitar cede s td In the
application for pishosal Work Construction Per..... o.--• �"• 4 --- ---- dated �. �..............
THE ISSUANCE OF THIS CERTIFICATE SHALL, NOT BE CONSTRUED AS R ,`NTEE THAT THE
SYSTE ,` WILL FU CTIQN SATISFACTORY.
DATE