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THE CO WOMMOUPhMMACHLI&S
-7 -, BOARD OF HEALTH
'owr�................OF.......o� -w,ov-i� ,
Appliration for Disposal Works Tonstr ion anti#
Application is hereby made for a Permit to Construct ()() or Repair ( ) an
System at: 1
*1 N� RA �K3- Y�rw,ov t�
Location - Address
. Owner
Installer
Individual Sewage Disposal
----•--•........ . .............. ..... --- ....------
- -.-- or Lot No.
........................... ...... �....
Address
Type of Building
Dwelling —No. of Bedrooms------ .�J.................................Expansion Attic
Other — Type of Building ............................ No. of persons...................,
Address •t -
Size Lot... Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Otherfixtures-------------------------------------•-•---•-•-•---•--.-:......--------------•-----•--------------....---------------••-......--•--•...._.............
Design Flow ------------- 5L5 ...................... gallons per person per pax. Total daily flow ........ 3 0 ....................... gallons.
Septic Tank — Liquid' capaciity-12R9-gallons Length... ...?- Width -.4_ f 2 -- Diameter ................ D th__.-- -..-.. _
Disposal Trench — No. ....... ............ Width ..... :9= . Total Length.... 25..-.... Total leaching area... _... sq -ft- P•
Seepage Pit No ---_-----_-------- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box (X) Dosing ank
Percolation Test Results Performed by.___ 1 -ha`'` :d .....q�r _e Date.._ ... -1 ........................
Test Pit No. 1 .... 2 -__minutes per inch Depth of Test Pit ..... 1._`x._6..... Depth to ground water .... ------
Test Pit No. 2 ----------------minutes per inch Depth of Test Pit... ----------------- Depth to ground water ........................
-------------------------------------------
Description of Soil-- .. -emsa .
_. .....1? � 1 ...................
..................................•----•---........--•----------------•-------....-•----------------.....-----------------------------------
---•-------------------------------•---------------------------------------------------•---•-----------•--------------------_-------•---...-•-------------...---•-•------------.............-•-.......
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 been issued by the board of health.
Signed...................................................................................... .......................... _....
/-� / /�� Date
Application Approved BY ---6'-- --.••/ =-� - - - . .................................... ---...�?..-2.3_::��_....
/ Date
Application Disapproved for the following reasons----------------------------------•-----•--------------------------•------------........._........----••........
...................................................... ....................................................................................................................................................
Date
Permit No.... g`1` .......................... _.... Issued_ ............ -.-- J? _ 2 .
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................OF.............................................
(Intifiratr of Toutpliattrr
THIS IS -TO CERTIFY, That the Individual Sewage Disposal System constructed (---)"or Repaired ( )
by-•••• r 's`�''.9�.:._� '"T:r�----------------------------------------------- ----.....--•--•-------•-----•----------------......-- -----•--.....------------
�` _ nstaller
at.......... �. ...•-� �� �-----:.�%"�f.__r. t� �r'----------------------•----------------------•----------------:.
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 ... =.%_:_Y: -P .............. dated ------- ._.. ��'.._ �?Sr..............,.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
c.............'� ......................................
DATE... ------------------•--•---....--•-•••-•-•...._. nspecor....L