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No.80:-14$--------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
170 W! ........... OF ..... ll .elV�'-aq:T l---------------
F
$15.00
s..........................
Appliratioo. for Klispoiial Works Tonotruriion ami#
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at
86 <2,QPT4w
- .............(........................................................ ...........-- .... .....M_A ... - 6Y •-•---------
L cation -Address or '0j5
o o.
AME -g.... b. 91-..f��: �Qar..1-17�------..iI / .? ..........:�N:!�!f ........................
PM Owner Address
—
W -
Installer Address �� � ��
Type of Building U Size Lot ............................ Sq. feet
U Dwelling —No. of Bedrooms .......................•...._... _Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons .................---------- Showers — Cafeteria
Q' Other fixtures _________ __________________
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W Design Flow.........................��------gallons per pQ,,h..-.
day. Total daily flow____._•_.---..___.__.... �.v.._._...._ gallons.
WSeptic Tank —Liquid capacity/aQ.Qgallons Len_��. idthA.1_�o` Diameter._._..•......... Depth`t-_:''4ry.
Disposal Trench — No- ----------------- - Width---------------th .................... Total leaching area ----_-------------sq. ft.
Seepage Pit No ------- I------------ Diameter --- __ Depth below inlet .... 4._.......... Total leaching area -.2 -0.4 -.sq. ft.
Z Other Distribution box (je) Dosin tank jj
Percolation Test Results Performed b .__'►�.c�'ss�lA/Plr,i .._. Date.vU•y i$ 197
Y m } ........... aa Test Pit No. 14W.2—minutes per inch Depth of Test Pit --- �fi2__.__ Depth to ground water. -/-Z.01' _._...._..
(i Test Pit No. 2 ---------------- minutes per inch Depth of Test Pit .................... Depth to ground water ........................
o� •-•---.--•----- ---------- -----------------------•-•--------------------------------------------------
Descri tion of Soil ---.45-13 -�3Li U/7-LAS....---�f=7!�%�.-.//�i ct'�U��'��
........--� r'-•-•- 49!9.9 ----- 1VffDZ(!i s'I4.v®------ oypoff'� -fix!- _L Cw 9-W!L'�...------...
13J'D L -----------------------------••--•-----•-•--------••------
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 — e undersigned urther agrees not to place the system in
operation until a Certificate of Compliance has been iued he ar of, iealth.
Application Approved By ------ ?_�........ :..di
Application Disapproved for the following
�n, ee'�
" ` l --r f ------------
Date
Date
PermitNo-------------------------------------------------
Issue<L.........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................�......0F... �...........................................................
Trrtifirtt#r of Tautpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed) or Repaired ( )
by....... ..4 �..5 �► ... IC C. $ t�..4.Y�--------------------------------------------------------•---------•----•---------------•-----....---•-----------....
Installer
at...... ----------------•------------------------•---------------------- ----------------------------------------------------------------------------------------------
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.____W.-148..................... dated ----- 6/1V.8 ......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C RILE® AS GUARANTEE T THE
SYSTEM WILL ON SATISFACTORY.
DATE - . Inspecto ... .
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