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PPJ &)A) rD THE COMMONWEALTH OF MASSACHUSETTS
T-9.6 BOARD OF HEALTH
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Appliration for Dispasal Worko Tonotrurtiatt 11trutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
9AZTe I 1>6_16.. \41L�_.f 170h-0 ��p 3-2— P-4g_ce� Au C)
No.
.......... q Lo -7 Rk0(T4,Q �. LA)
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Owner Address
W.................................................................................................. ...................................................................................................
1.4 Installer Address
� Type of Building Size Lot ..... Sq. feet
U
Dwelling — No. of Bedrooms ...............- -----------------_--- Expansion Attic Garbage Grinder
04 Other—Type of Building ............................ No. of persons ............................ Showers Cafeteria
04 Other fixtures ......................................
4 SOL ---------------------------------------------------------------------------------------------------------
Design Flow ............ U0 ----------------------gallons per pown p�r,4ay. Total Oily flow .............. I-V+ .0 ................ g-41ons.
Septic Tank —Liquid* capacity-M.00.gallons Length.2)1;.... Wid&2�'-10'.- Diameter ................ Depth._.'L4..,...
Disposal Trench— No ..................... Width.................... Total Length.............__..._. Total leaching area .................... sq. ft.
Seepage Pit No.-----_ J� ............ Diameter..... t.0 ......... Depth below inlet......... �? ...... Total leaching areal -Q. -P ... sq. ft.
Other Distribution box Dosing tank ( )
1-4 _TA T>tk0J4_S .......... Date ..... ..........
Percolation Test Results Performed by..... .............. I .......................... ....
Test Pit No. 12. ..minutes per inch Depth of Test Pit....l ...... Depth to ground water ...
44 Test Pit No. 2_�L�minutes per inch Depth of Test Pit ...... 1.ft �_ ---- Depth to ground water...) `?!s6.....
P4.......................................... I( -------------------------------------------------------- ------- ( .......................................
0 Description of Soil... ...... ti_t ... ..... .................................
cu
b-eZ4" Etut- 7
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U Nature of Repairs or Alterations — Answer when applicable......-.........................................................................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TAII'Ll; 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 boar o -DA health.
Application Approved
X
Date
Application Disapproved for the following reas&ns: ....... M ................................
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Date
ep.
Permit No ... 0.0 — 6110 .................................. Issu,
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Date
THE COMMONWEALTH OF MASSACHUSETTS
e--_, BOARD OF HJEALTH
10�..... ...........
.................................... OF .........................................
Zrrttflrate of Tautpliattrr,
THIS IS TO CERTIFY, That the Individual Sewage, Disposal. S,Vstem constructed 114 or qtepaired
by ..... L_t4
L
7. . _Zll�;,,�,t ........
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...... �J.slaller
'at ....... .
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has been installed Vccordance withheprovisions of of The State Sanitart)Cr)0 in the
applicationfor Disposal Works Constucti)n PCr ------------- dated. ..............
ATE -SHALL NStRUED AS -GU RANT I
THE ISSUANCE OF THIS CERTIFICATE NOT�" AT, THE
SATISFACTORY.
SYSTEM. WILL FUNCTIO�,
DATE..... /j. . I ...I..I...Iris
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