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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH l
........... ...............................O F..._..................................------•-----........_.............................--
Appliration for Disposal Works Tonstrurtion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ("--an Individual Sewage Disposal
System at:) Uj
.... �It !. ..!........E96.9 ---•......................... . - ................... ..............----•-
Location - Address or Lot No.
.............MIL. .F_ &s... ....................................................... ............................ F.. ---•----------•-----•-----•-----•----------•--
Owner Address
CtL�.CGru 5T TWG-W"ut b2G3i
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Installer Address
Type of Building Size Lot ____________________________Sq. feet
Dwelling —No. of Bedrooms ......... .............................Expansiog ttic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons ......... Showers Cafeteria ( )
Othertures------------------------•--------•--.....------•------•--------•----------••--•--------------------------......----------------••---••---•-......_._..
Design Flow ............ ®---•-•---•-..._._._._ gallons per person .daY•
Total dai}y flow.......__9........................ gallons.
Septic Tank — Liquid capacity&P _gallons Length ....__._._.
Width.._,S........ Diameter ................ Depth ................
Disposal Trench — No ..................... Width ..... v_ ------ _----- Total Length ............ V_---- Total leaching area .................... sq. ft.
Seepage Pit No........ ....._..._.. Diameter ........ ........ Depth below inlet ...... �__________ Total leaching area..................sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ....................................
Test Pit No. I................rainutes 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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�-� •�....... a
Description of Soil ........ _.C_ti1 ---- •--------------------y-----------------------------------••-------•----------•--.....---------------------....._...-•---.....
-----•-------------------------------------------------------••--------•--------------------------------------------•---------------------...-••-•-••--•--•------ .. _..........._-_... ......
Nat re of Rep •rs�gr Alterations—Answer when applicabine..____✓Oi7ta__U��_.%,4 r,____ t_✓_ ....raG�� ls�..--
r�-- t� K---•- ------- L 1 b I v E_ k ------2-t -`-'• x--••--......----
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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 be is u d by e board of health.
Signed. `t �. �• .... °
Application Approved BY--•_---•rfowin>gasons:
.....DateAPPlica.tion Disapproved for th----•-----•-•-•---.._.....-•--••-•---•----•--•-------•---•-••••----•-•••-••----•-•-••...•-•••--•-••..__........-
..----•-----•---•---•--••---------------------------...----•-•------------•--------...-----------------------•-------•---•-•----• .------------------ --------•-•................
twr C9 � 1 (9 (5Date
PermitNo ..... ................................................... Issued- ------- ...............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTHt���c�
.....OF ........ N:: V. .:...................................................... -� r
( ertifira ti of Toutplittnrr
THI IS TO CERTI Y, That the Individual Sewage Disposal System constructed ( ) or Repaired (4_. -•
Installer
at............................................ ---•-----•-•--•--------------------•-••-••----••-•---------•--......•--••_..........---•••-- -------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod g as d�described in the
application for Disposal Works Construction Permit No.-c�'_'-_L ��_`�............... dated_._ ___t✓_� I>- ._.__ -------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA GUARANTEE THAT THE
SYSTEM WILL FUNCY-ION SATISFACTORY.
DATE--------•••-.....��' Inspector__...J�� ;;%�' - -------------------•--
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