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THE COMMONWEALTH OF MASSACHUSETTS
/_
BOARD OF HEALTH
-/----�/�C//........... OF .......... 1..!2CI a.64l. f--------------------------------------
Appliration for Biupouttl Works Toustrurtion Prrmit
Application is hereb made for a Permit to Construct ( c -)-6r Repair ( ) an Individual Sewage Disposal
System at: �� !✓j'�e�'
.....A.. 7�,-e
QLocation -' i il..
1Z
dresses.!_7 lh'J 41 ..............
i Owner
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Installer
Q f.. —0..----------Z-�/Z,0L.;r .........
or Lot No.
Address
Address
Type of Building Size Lot._/_..1°.,...Ca-0_Q..... Sq. feet
Dwelling —No. of Bedrooms -------.--_ I.............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures---------------------------------------8------..-------------•-•-------------•------------.._...........•--•-----._..........-----•----•-......
ft
Design Flow --------- f/U..........................gallons per pexsen per day. Total daily flow .......... U._...... _............gallons.
Septic Tank — Liquid capacity/094-gallons Length_.8-' G.._. Width_.4F ',/'P-.. Diameter ................ Depth ... &-_ ,._
Disposal Trench — No.-./ .............. Width .... eo _ ....... Total Length ...... /Z......... Total leaching area._ Z G s _--_---sq. ft.
Seepage Pit No ---------- '---------- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box Dosing tank ) // /
Percolation Test Results Performed by.---%�___-:---�I2iy____________________________ Date �,l g_`/___.______..
Test Pit No. 1 ...... 15.'L -..minutes per inch Depth of Test .... -----
Test Depth to ground water -___--__-------------
Test Pit No. 2....L t ..... minutes per inchDepth of Test Pit..../ ZU ....... Depth to ground water ...... 9_..............
------------------------------------........................................................ .........................................................
Description of Soil.
...................
Agent :
he�T w
rovisi o
�o ,ration ul
Application
or Alterations -4' Answer when applicable --------------------------------
(l'ersigned ag/es to install the aforedescribed Individual Sewage Disposal System in accordance with
Is
of TITt 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
.til a Ce Ificate of Compliance has been issued be�y the board of 1 ealth.
"M X
................................... ................................
/Pproved By.. � . = ---•-------•----------------------------- -� ���
Date
Disapproved for the following reasons:----•-----------------•------------------•-------------•------•---------------------------...----------••---•--.
Permit No ........ - r ................
------------------------------------------------------------------
Date
Issued ------------'
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD /C.
OF HEALTH
7�du!.'1....................OF.........�G'r�r�......................................
�rrfifiratrTompliana /
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by--------------------- -�L!.6-•----....M.6,57..#._.....-.CCW..,5-r&-t-----•-•---------------...--------•---........--•-----------------•--•------------------....._
l
at.sf
Installer
/
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 ......... �.__=_1l`��-.. dated ..............! ------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector
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