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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ..........................................................................................
Appliration for Disposal Works ntrnrtian thrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Syste at
.......................
-. ..
�^^' Lo ion - Address
/.:!�:���-l�T---------- ----•---------- �L.,,rj-��-� e!.�4. �'1�t1 e:�e�f.S.�-,r4•�•s---•�
owner Address
.................. �_.B--- ------------------------------------------------------------- --•--------...........................••••-•--••-•------.............................
Installer Address //
Type of Building Size Lot ..... !..... �n. �0---- Sq. feet
Dwelling —No. of Bedrooms ............ .......................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixt res---- •---._...-----------------------------•--------------------------------------------------- .....
Design Flow ........ ......................gallons per person per day. Total daily, flow... ..................... !?t............. gall 7S.
Septic Tank — Liquid' capacityt/ a gallons Length.._ 4 ...... Width ... Diameter ................ Depth.. _...........
Disposal Trench— No...../ ............ WidthZ ........... Total Length..Z-�:......... "Total leaching area Z-__- .-.----sq. ft.�
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area, __% �q� t. f%/pl�.
Other Distribution box Dosing tank ( )
Percolation Test Results Performed by ...... __l. Date......... J,/ __
Test Pit No. 1 _.:"inutes 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 ........................
Description of Soil ........r .......,..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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en 'sued by the board of health.
Signed ..... --- -- ; .�. o (�
Application Approve By ........ ......... - -- -- ----- -- • . -- ..... ......... ..........................
Application Disapproved for a following reasons: ..............
........................... ......................
----•----•-------.------•..............••-----•--•--•-----------------.--••------------------------------------------------•-. - — Z_-
� /date
Permit No...... • .............. ....... ...... .. Issued-----•------- /
---....................
ate\
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ...............................................................................
Trrtifiratr of Toutpiiattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at----------------------------------------•-------.:--.----------.-------------------------------------- -----------------------•-----------•-•-------------------•---•--.----------------•-------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application, for Disposal Works Construction Permit No ----------------------------------------- dated_._..___._......................._............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRU. A GUARANTEE AT THE
SYSTEM WILL F N 10 SATISFACTORY.
DATE.............. �................................. Inspec .. -- ----- --- ....__. _.... -