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THE COMMONWEALTH OF MASSACHUSETTS
---BOARD,. •%� HEALTH
--------- --- OF...
ApPration for Dispaiiai Vurks Tonstrurt .rruti#
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
S tem at
y � 0% L
.. � �� V .. ^.......................... � ���:.... Lot No.
.. { ..?..!. �.� �...--- -
Lo n -Address or
r Address
Jo.✓,' ----Aell red-----------------------------------------------`------....�.....................................................................
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms -------------------------------------------- Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons__------..-_____---_-.___. Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------.....-----------------------------------------------------------------------------•----------•--
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid capacity ............
gallons Length ................ Width ................ Diameter ---------------- Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... 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. 1................minutes 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---------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------
Nature of Repairs or Alterations —Answer when applicable,1at'-d-, ------- �1:-. ........................................
------•-----------••----•-----------------•---------•-----•--------------- ----•-------------.......--------------------------•-------•-----•-------------------------.....---=---•-----•••-------.----
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' ha�ss been issued by the board of health.
Date
Application Approved By .......... tieealth.-OffWWicer........................................................ ........................................
Date
Application Disapproved for the following reasons-----------------------------------------------••••••••••---.•-••-----------••-......••-••-•••..---
Date
PermitNo --------------------------------------------------------- Issued ------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF, HEALTH
.......................................... O F....................................................................... ...........
:..-
Trrtifiratr of Toutpliaurr
THIS IS;I.a.�7ERT FY, T tthe Individual Sewage Disposal System constructed ( ) or Repaired
by......---•--------...,! �:..F. ...v,/:��r=---------------------•-•---------------------- . ----.._....................----...------. --
#. .'f� P:I alley
at._...--- --- #f.---------------------•'r-------------------
has been installed in accordance with the provisions of T TLF�` 5 of Thg State Sanitary Code as descri ed in the
application for Disposal Works Construction Permit No.. `" ..._ dated//--°"":/,.d_.. 7 ........--._..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector