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App-Permit-Compliance
Fss......i. ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... OF ......... X 9.2q� ' --••---•----•-------------------- Appliration for Disposal Works Tontrnrtion 1krmit Application is hereby made for a Permit to Construct System at: Location%r__l..0 x.._ Installer Type of Building Dwelling — No Other — Type or Repair (� an Individual Sewage Disposal MCL _ _... T. t-N�.._T.�1-�' _�t--�---^--h'---�� Address '.__Yo'. z ---------------------------------- Address Size Lot ---------------------------- Sq. feet . of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) of Building ............................ No. of persons --------------- ............. Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------------.--------------------------------._.----------------------------------------------......._------ Design Flow -------------------------------------------- gallons per person peg day. Total dagy gow-------------------------------------------- gallons ! Septic Tank — Liquid capacity -/Y4allons Length-_ .Q.-b___ Width --- SI---- Diameter________________ Depth.... Jr .. Disposal Trench — No ..................... Width .......r----------- Total Length _............11.... Total leaching area -------------------- sq. ft. Seepage Pit No -------- I........ Diameter .......... 4(------ Depth below inlet ........ ......... Total leaching area..................sq. ft. Other Distribution box ( / ) Dosing tank ( ) Percolation Test Results Performed by-•---••---------•-----•-----•--•-------•--------•--------••......----•--- Date ........................................ Test Pit No. 1................fninutes 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 ........................ Descriptionof Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -•-------•----•------------•-------•----------------•-••-------------•-•-•--••--••--•-•--•----------•------•--•---•-----•-••----•-•----•------------•----......------•-••--•-•------•---•-------------.. ------------------------------------------------------------------------------------------------------- r---------------- ......... --------- _ Nature of Repairs o Alterati nnss — Answer when applicable.-._� _s�. ©�___-_. S- .._ _ .......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITiZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been sued by the boar of he lth. (yam' w• . 4J Signed �� 1 _ ate Application Approved By--• --- - ---- --------•-------•-----•----•------------•....-------------------5 'Dat Application Disapproved f ...................................................... ._.......Y..... ........ J_.._._______.___________.._._._..._...._....__.__._._.-----.._._._----------__._. _.. _.� .......................... j� / r D to Permit No. ----------------•--•---•----.....---•-•--_--- Issued `{/� Date I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......:...........OF............../J..6.3-1-I r?, t%. ' .141.........-•---.............. Tnrtifiratr of Tompliaurr THIS I� TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ) by - ' '�_ � "��. %1.�!�?t� !_ L: f........' �� :rr� .......1:._............................. , �.-------------• • - _ Installer 1 r at '�' 1 ! v I _.. ----------------------- --- , _----.?_ _ --: r„ has been installed in accordance with the provisions of TITLT 5 of The State Sanitary Code as d scribed in the application- for Disposal Works Construction Permit No.__ �_`C..-t- �._J .................. dated__..__��lx / ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............. _,1..` ........ Inspector-• ---- �-•-------------------------------•------------.----------