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THE COMMONWEALTH OF MASSACH SETTS 2/�1
BOARD OF HEAL
...................•-•--......OF ..........................................................................................
Appliratiun for 14sposal Works Toustrur iurt Ilrrmi#
Application is hereby made for a Permit to Construct (>�or Repair ( ) an Individual Sewage Disposal
System at :..',. M 419= t Or=
................ A �d.s .... �.. v.......... .-----...- - - -..._ .� L .-------------- ...... -------------•-----
--cation - $re;s ---• or Lot No.
........... ...� ?��. LJ-�---------.................. _..--•----•-------........----- ...----.......---•-•-----..........---......--•---•---
n -b-✓ Address
Installer 21 Size Lot --•-•.-dress Cl�+
Type of Building Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) A)o Garbage Grinder ( )
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures
----- - -- - - -
-...
Design Flow ...... z _. -.._ �i I�' ..__.gallons per person per day. Total dail ow.........Z �.................. bus.
Septic Tank — Liquid capacity!"- allons Length ......... ..- Width....- Diameter ................. De,Pt"h
l_.......
Disposal Trench — No- -------------------- Width..=?--�.•...... Total Length--.. ........ Total leaching area__/ -5E- _._sq. ft.
J
Seepage Pit No ..................... Diameter .................... Depth below inlet ----- ,/__._........ Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank( ) l
Percolation Test Results Performed by ............................................... . Date..... / - ' .......
Test Pit No. 1.. 4.21...minutes per inch Depth of Test Pit .................... Depth to ground water ...... ..........
Test Pit No. 2--.4._�.minutes per inch Depth of Test Pit....... ------ Depth to ground water ........................
-------------------- -- --- ------ ........l
Description of Soil Tl---•------------------ _ -
---- -- - - -•-•---•-- --•-- - - .---- --- --
•P j-a
.----•--•------------------•--------•-------------•-•-._......--•--------------•----------....•-•---•----...---------•-------•-----•-----•------•-----••----•--...._....-----------------...------------.
•--•--......----•--------------•------------------------------------•------------------•-----------•-----.......-----------------------------.........._....._....--------•.........-------•---------...
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 systM in
operation until a Certificate of Compliance has been issued by the board o4ealA'—�
Application Approved By.. ---- - --- -
Application Disapproved for the following reasons:....
Permit No.. ' .3-------------_--------
Date
Issued-.......................................................
Date
— — — — _
THE "EOMMONWEALTH OF MASSACHUSETTS
/ Y- •' ` BOARD OF HEALTH
�?
,Y ........� „�............... OF ........�
�`� farr�ifutt#�e ,af 'faunt�rli�nr�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed k/) or Repaired ( }
( ........ ... ... _............------........ ---•- ..
-•---•-•-------...................................--
.9� %% /"1 / 7 Installer.
at ............ ,SZ ..... / s........C,7,7 - J . /- ---
has been instilled in accordance with the provisions of TITLF� 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ ._.��_.__.. �..........
THE -ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE``
SYSTEM WILL `FUNCTION SATISFACTORY
3 / - Inspector.... ,�----............ ............. --------
DATE....._.... --------------•-------....--- -