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THEBOARD AOF OF
HEALTH TS / (�
------..mot .t4 ----------------OF......... YAR.470411rll....--------•--------------------•---....-----
Applira#ion for Biap sal Works Tontrnr#ion rermit
Application is hereby made for a Permit to Construct ( ) or Repair { ,X) an Individual Sewage Disposal
S t t•
...... -- - /,2,.7 - . R vEg----- a .......................
Locatio - Address
...................... - �l a �.ff� ........................................
Owner
................... 7 t �_. .� _112 ' =----------------------------
Installer
ZdT LZ(Li?j MAP- 2Q-
J� or Lot No.
--------------•---------------------•--Ve ...................................................
Address
Type of Building
Dwelling — No. of Bedrooms................�J.............. Expansion Attic
Address
Size Lot_�`�r S_ ---- Sq. feet
Garbage Grinder (Ali
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------.-----------------------------------• ..........................................................
Design Flow .._........��.....................gallons per person per day. Total daily flow.__......_ A ..... _............ gallons.
Septic Tank —Liquid capacity L0O_gallons Length -__ Width ... .jjq `t
Diameter ------- _-------- Depth_LS!4_./_ 1
Disposal Trench — No ..................... Width _..._._........... Total Length _................ . Total leaching area .._....._......_....sq. ft.
Seepage Pit No .... NE-_-_-_- Diameter ....... ."__.... Depth below inlet--- � 3...--- Total leaching area Z4:! 7.4F
Other Distribution box ( L -Y`_ Dosing tank )
Percolation Test Results Performed by ..... -_/_.,Ai:�I(.tvpS_....._.k SA--------------- Date....-9.I�!g.I.%.. 7�,_-.
Test Pit No. 1 _ A-.-./�)_-minutes per inch Depth of Test Pit ---- IS3 ---- Depth to ground water ----- /./ .........
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ..... ...................
Description of
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----------------------------------------------------•-------------------------------..........•-----------•-------------•-------. _............ _..
11
............ -------- -----------
Nature of Repairs or Alterations—Answer when applicable..�C_pGE._.1�v1____l.T_...........
------------------------------•----------- : -�sir-1
Agreement: sc� b /S �'4 f qJ 7 /D /1' - %® ace S*kj'!
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T ITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been 1ss the oar o ealth.
Signe .-----_.
.....-----•--...-••------------------ .......... .
Application Approved BY ---•-------------------- ----------- a
7 to
Application Disapproved for the following reasons/ ------_---- -----------------------------------------------------------------------------------------------
.............................................. ----------------------•-----•-------------...----•-......------------------------•-------•--------•-•-------------------...------------------------------
® Date
Permit No..... 7'- ------------------------------ Issued_ .................��� .._.._.._..._...
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f/?...................OF.......................
Trr#ifira tr/ of Tontplittnrr
THIS IS TO CERTIFY, That the Individual, Sewage Disposal System constructed ( ) or Repaired (X)
z
has been installed in accordance with the provisions of
application for Disposal Works Construction Permit N
THE ISSUANCE OF THIS CERTIFICATE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE-------------- /l --el
..�-----------------------------------------------------------------------------•
5 of The State Sanitary Code as described in the
. 3 3-Z---.. dated ----------- i :::��-_-------
SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
Inspector ---- -_ - ................