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THE COMMONWEALTH OF MASSACHUSETTS
BOARD Oi= HEALTH
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Appliratiou for Disposal Warks Toustrur#iou jkfmi#
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Indio dual Sewage Disposal
System at
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---- canon -Address -D a ` or Lot No.
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....................... ........ - ..H! �:...�. ..........-•----------......_
Owner Address .
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a -----------••-------- --•............. ............-----------
m Installer Address
Type of Building Size Lot ... AA4�-------Sq. feet
Dwelling —No. of Bedrooms ..................... 2 ................... Expansion Attic ( ) Garbage Grinder (— )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .......................................... ............................................................
Design Flow .-----•---...-__!-t�?-•-- ....gallons per rse per day. Total daly� flow.--_ z Q -------------- �gallgnS.
Septic Tank —Liquid* capacity..h24a_gallons Length-.$......... Width -4'.1.-------•- Diameter ................ Depth .....ff....
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No.. ---•--_--.I....... Diameter ....... 1.p_'...._. Depth below inlet ....... �a-....._... Total leaching area ... Z?l._...sq. ft.
Other Distribution box ( ✓) Dosing tank ( )
Percolation Test Results Performed by ........ R,..$)----•__P_..'.hfF hN_,�.lth<G................. Date.......1-!A?�V ._.._...
Test Pit No. 1... 4-.Z .... minutes per inch Depth of Test Pit .... _�4f...... Depth to ground water>lk9.f *M'yP..:
Test Pit No. 2_._:4.1 ._minutes per inch Depth of Test Pit ------ 8_".._.. Depth to ground water.aQ;' 1 AW—
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Description of Soil ..................................=------mp?Vr1&csAo.P.... _------•-----------
...................•-•---...---.....--•---------•---------------.......... .:[`QS?1:1 R --------•---•-----------....----••-----...-- •-----..:-....---.....--•---•-•---------------
--•••------•-- -------•••----•---------------------•---------••-------------•---••.....-•------------•--.........•-------•---...--••-----••-----••-•--•--•.....•------•---•--•-----------•---•-•----•---
NattT,e 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 Co The undersigned further agrees not to place. the system in
operation until a Certificate of Compliance has bee iss d the board of 1 lth.
Sied --• - -----------------------
AppliApplication
cation Approved By -•••-----• .............................................
Date
Application Disapproved for the following reasons- ---------------------------•----•----.....----•--------------------............---------•--••-----•---•--------
...-•......................................•------^-------•--------.........----------........---------.-------•------•---...--------------•---...------------...-----........-----•-----------•------.
Date
Permit No. r�.........! ..
-........ Issued..... -(. n� ............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
�- BOARD 9F HEALTH
...../ Ccv/1/................ oF........ :/�4 1.� 1/..............................................
Trrtifiratr of Tout rliaurr
THIS IS CERTIFY, That the In vidual Sewage Disposal System constructed or Repaired a'
.. 1 �_l.
ra -.at Jf ._ ...... !L -/i': .._. {C lll. tatter --•----------------------------------------•--
has been installed in accordance with the provisions of TIT F r- f The State Sanitary Code d cribed in the
application for Disposal Works Construction Permit No.____�-�'._��� ------ dated.....- . ...... .. ......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G RA TEE THAT THE
SYSTEMA W L FUNCTION SATISFACTORY.
DATE = - /.......................... Inspector. ��1--•---. f '...... .