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THE COMMONWEALTH OF MASSACHUSETTS
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BOARo of EALTH
V.............OF...............'... y�"(��`...
Allpliratiun for Diu ruu Turku Tonsirurtion Vvermi#
Application is hereby made for a Permit to Construct
System at
..... ._ .. � . ..... ....................
s ..
✓� 0 // /'� o�yner (----------•-----•----------•(-•-�------------------------------------------•-----
Installer
Type of Building
Dwelling —No. of Bedrooms ................ ........
Other — Type of Building .........................
Other fixtures .......... ..................
Design Flow ..................................... • ---gall ns
Septic Tank — Liquid capacity ... ....... gallon
Disposal Trench — No . .............. .... Width.....
Seepage Pit No_____________________ ' meter ...............
Other Distribution box ( Dosin
Percolation Test Results Performed by...._
Test Pit No. I................minutes per inch
Test Pit No. 2................minutes per inch
or Repair ( an Individual Sewage Disposal
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— - Lot No..........................................
"000/h //� // { j press
........ !_1..!.!. -.......
----------------------
._....------------
Address
Size Lot ............................Sq. feet
.....Expansion Attic ( ) Garbage Grinder ( )
of persons ............................ Showers ( ) — Cafeteria ( )
.........---•--------•--•-•---•---------------
person per day. Total daily flow............................................gallons.
g
Length ................ Width ................ Diameter ................ Depth ................
............. Total Length .................... Total leaching area -------------------- sq. ft.
._.. Depth below inlet .................... Total leaching area .................. sq. ft.
ank ( )
----------------•-••-----•-----...-•----•-•-----------•-----------_. Date ........................................
epth of Test Pit .................... Depth to ground water ........................
Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil .......................................................................................................................................
.-------------------••--•-------------•---•----.....---------•------•----------------.....-------------•-•--------------•---•-------.....------.....-----------.........
-------------------------------------------------------------------- ............................................. Nature of Repairs or Alte ns —Answer h l' ble..__6.�4�/-__ :a
............ " �
..--------
=
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued he bo rd of health.
tgned..-------------------------------------- •---•--•------•--•----•- ���i
ApplicationApproved By ............... ••-------•-------------------------------------------------------------
Date
Application Disapproved for the following reasons: ................
---------------------------------------------------------•-----------------.-------------------•--------------------------------------------------- •--------------------•--------- .._.. ...
e
Permit No... ���
•----------. Issuea_ j ---- --- ---------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
/41
,.9irffiratr of Tomplittnrr
. y,
TH-1S IS TO CERTIFY That the Individual Sewage Disposal System constructed (f ) or Repaired
by.... f{. ,_ .-7 ......... e_ ei -- "2 ------------------------ ----•----•----•-----...........--••--•-----------.........----...---------
j� f f Installer
i....................... •......................... ......................... •.........................................
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'lPermit No.__�: r�_.._... 3J'/........... da.ted..... k-:_. G_ ___a' ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION, SAT;,S`FACTOIZY.
DATE......... 5 r
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-. ....... ....Inspecto --•-•-. :: � . --- s ���...:.A- ....._