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No.._.. .............. F)mB .... a.i ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... lo'. w. 4j•..............OF..... . �ARAJ ;;i?•77-ul ............................................
Appliration for Dispaiial Works Tomitrurtion thrmit
Application is hereby made for a Permit to Construct (X or Repair
an Individual Sewage Disposal
System at:
A L0-71_12
................. ....................... ............... ................................................
Location Address or Lot Ik
-f Z4.4e�7;11
I ..................... .. .............
.j
;Ogwn,
................................................................................
.
Address
Installer
Type of Building
Address
Size Lot ---- Z ----- S._"?'*;:ASq. feet
Dwelling—No. of Bedrooms ------------- 5 ............................ Expansion Attic
Garbage Grinder
Other—Type of Building ............................ No. of persons_________._________.________
Showers ( ) — Cafeteria
Otherfixtures ......................... ----------------------------------------------------------------------------------------------------------------------------
..............
Design Flow ............... ................... gallons per person per day. Total dail flow.___..._.__ . _5.ao ... .............. gallons.
Septic Tank — Liquid capacit3OVO.0.gallons Length .... �t2VWidth ......
Diameter________________ Depth___ 4 ........
Disposal Trench — No_ .................... Width_______.__. ________ Total Length________........____ Total leaching area ..................... sq. ft.
Seepage Pit No ........ / .......... Diameter___Depth below inlet___.__ . ........
Total leaching areas t-19.eq-ft: 6P41
Other Distribution box Dosing tank ( ) -
Percolation Test Results Performed by .... 4�49ks? ..... 7-------
-*I -
Date
Test Pit No. I ... 15�' ...minutes per inch Depth of Test Pit ---
Depth to groWFwa&r$V_&/AA
Test Pit No. 2__===rTt..minutes per inch Depth of Test Pit __._°_....
'k
Depth to ground water4 ...................
.... * --------------------------------------------------------------------------------------
Description of Soil_____ . t.-5- ._Z.17.74 . . .___._RL- -?9A) -------_-----------
........................................................................................................................................................................................................
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 TIT 1:2 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b sued b twoard of health
Sig . . . . ."G. .... .. . ........... �/�a
Date
Application Approved By -------------------------• ... . . ...... .. _.._-r . - --------
Application Disapproved for the following reasons:....
...................................................................................................................................................................................
Date
PermitNo ------- s -------------------------------- Issued .......... ......................
to
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tatifiratr of Tompliana
THIS IS TO CERTIFY, That the bdividual
( V or Repaired
.CV,
at ................................ ................................ A .............. / .. ...... . ...... ......
..... .........................
has b . een installed in accordance with the provisions of "LITL�5 of The State Sanitary Code as (YQscribed in the
application for Disposal Works Construction Permit No._ .............. dated ------- - - f/f---------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
T-% A nl"L-