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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-• ............ ............--.-----....O F......................................----------...............--------...................
Appliration for Dhipos al Works TomitrurtionqM' d
Application is hereby made for a Permit to Construct ( ) or Repair {� an Individual Sewage Disposal
System o t : _
..N rr cX4,1 00 was .. , � L a fry t) ��-
Location -Address o or Lot No.
... ...... - ...... ............
Owner Address
Zv car
------ --------------
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 ..................
----------------------------....------------------..........-----------------......_._._..--- ---------------------------------------------------------
Description of Soil ........................ �'�........ s.. ahem. ..... %��C/ �f..... 4?! , ....--------------------------------
------•----------------••----------------•-•---------...-----------------------------•------------------------------------ ----------------
X42..!!le"-------------------/`2d�---- ---`-- ...................................
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 TIT1 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 by the board of health.
Signed- ---------------------------•----•---•--------
............-�Da (��
ApplicationApproved By ................ �.-••---••-•---•----------------------------------------------•- ted
Application Disapproved for the following reasons:---•----•-----------•--------------•-------------•-----••-----------------------•--------------------...---•--..
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Iff
Date
Permit No........ i �....------�-------------------- Issued_ _. �_l...........................'
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................... OF ............... YARi+OM................................................
(irdifiratr of Tontlrlitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....... irc-.;BVH 1F-- M...-----------------------------------------------------------------------------------------------------------------------------•--------------...------......--
Installer
at.........T-B'RT,M.AIM---%-Yw................................................................................................................................................
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.__82_80......................... dated ...... v4/82 --------------------------
THE
4 f82.___ --_---.-.-------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BECLTRUEDGUARANTEE TH THE
SYSTEM WILL FUNCTIONS TSF TORY.
DATE.----...-•........... . ... .. _�............ Inspector... ..._._ .._ -----�=6-----....