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,No. --_.._.. South Y�,I ;, t�' i wli ,€ 'A 0265� Fps ............._ ...........
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THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
........... OF .......... .1 CJ--. ------------------------------
Appliration for Disposal Works Tonstrurtion "trout
Applicatio is , hereb d or a Pe it to s ruct or Repair ( ) an Individual Sewage Disposal
E.
-System at:
\ Location -Address or Lot No.
...................... ___»...................................................................... ......_.................-_.....
Owner ............................................ Address
Installer Address
Type of Building Size Lot ............................Sq. feet
a4 Dwelling —No. of Bedrooms ........... 4............................ Expansion Attic ( ) Garbage Grinder ( )
pOther — Type of Building ............................ No, of persons ............................ Showers ( ) — Cafeteria ( )
a Other fixtures .....--••----•----------•------•-------•---------- . -
W Design Flow ............. ---------------------- gallons per person per day. Total dail flow__________ 44-4� ................... gallons.
WSeptic Tank— Liquid' capacit/90 gallons �Length_____43 Width ....... Diameter________________ De,{��___ ..`...._-
x Disposal Trench — No. ..... :�............. Width ---- 1____........ Total Length ...... �_. Total leaching area._1.�_7_____r�-sq:-ft.c P1a
Seepage Pit No ........ �F....... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box (u� Dosing tank ( ) -
� L� Cx! // ti% 4 J 1 Z- ! -�.66,
Percolation Test Results Performed by .....................?X..__..0 __... ".4�A' ._./.._........ Date___________________. ___________...____-
Test Pit No. 1 ... .Z_._minutes per inch Depth of Test Pit___,f�I.. a.. Depth to ground water .___ 0.a
Test Pit No. 2................ minutes per inch Depth of Test Pit .................... Depth to ground- water ........................
-------------------- --------•---•--------....-•---_-•--
Description of Soil ------------------•--------1 4t__? F............ R�i�- -R.4--A!,J ---------------------------------------
-------------------------- ---------------------------------------------------------------•----------------------------------------
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 LITA IZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu by the board of health. �� ` `
Application Approved By___ ___-- __V'-p`.j
Date
Application Disapproved for the following reasons:
�— �
PermitNo... .........................................
---------------------------- 1;................................
�/� ( 11
Issued. ...... — ��`` -v 5�............. au ....
Date
THE COMMONWEALTH OF MASSACHUSETTS —off
BOARD OF HEALTH.
.......... ..... ................OF... .l................................................................................
Tntifirat a of Toutplinurle
VHISXS T� CERTIFY, That the Individual Sewage Disposal System constructed (+--1-or Repaired ( )
bY---•------•-------••=-------------------------•--
Installer
---- -----• '--------------------------------------------
at(....................................
-----------------------:..------- • -----• -----......__..._..-----
has been installed in accordance with the provisions of TIThE -j of The State Sanitary Code a described in the
application for Disposal Works Construction Permit No._____ __.__ _ _______________ dated _-(A_��:__�D-5__ ---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUAD AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY �
DATE - .."" ._----- •---•-_.-... Inspector .....
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