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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T------- ..... OF ........... Y...o..._� ...................................
Apptiration for Uigpoual Works Tomitrurtion frrutit
Application is hereby made for a Permit to Construct. (X) or Repair ( ) an Individual Sewage Disposal
System at:
4.9.v2ff' Lori 9.�E / 9.A6 ............... W.
- Location - Address or Lot �p
........ . � _ 4.....%-h.�.rl�!2 �.-----•-----------•--------- J
!' , Owner Address
------------ --- `---'• '.. YS ..e 5--------------------- ... ............. Address.-•------..--..............................
Installer
Type of Building Size ----Sq. feet
Dwelling —No. of Bedrooms.................3.__..._._............. Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
a Other fixtures .................................
W Design Flow ....... 11.0 ............................ gallons per perso per day. Total daily flow --------- - 3.O ................. gallons.
WSeptic Tank — Liquid' capacity./OOOgallons Length.-'_- 6 Width_ ¢'.'A4 Diameter_____________ __ Depth....s_'¢_''
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ....... /............. Diameter.../4__FT. Depth below inlet .... 49.E7:..._. Total leaching area .... 4�4._Z..sq. ft.
Z Other Distribution box ( X) Dosing tank ( ) /
F" Percolation Test Results Performed by.... --------------------------------------------- ....................... Date ..... y Z:f//e ............
Test Pit No. 1_.L.Z_____minutes per inch Depth of Test Pit.... Depth to ground water ........................
Test Pit No. 2_-::::L7 _ ..minutes per inch Depth of Test ...... Depth to ground water .......... ---........
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Description of --------- lao..tnA_�?
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...._ CK. 0 V N_...n71Ci? .7f'J_._ % /�iN ...............................
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.
SiX'.
neD
.
/-� Date
Application Approved By ............ • ��-----•------------------• --- �- ?A',7-�-20------•---
Date
Application Disapproved for the following reasons- -----------------------•--------------------------------------------------------•-•-----•-...------------------
.......-••-•-------•---.....---•-•--•-----------------•--------•-•--•---------•----.....---•-----------•--------••---------------•---------------•- ....................................................
Date
PermitNo --------------------------------------------------------- Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tntifirab of Toutpliaurr
T RTIFY, That the Individual Sewage Disposal System constructed (,\) or Repaired ( )
Installer t
at------------------✓�r,e---------------------------------------------------------
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 ..../�!'_ "/': __% ..__...... dated _;" /.: .._,r�__.� ...........
THE ISSUANCE OF THP CERTIFICATE SHALT +TOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION :SATISFACTORY.
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