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THE COMMONWEALTH OF MASSACHUSETTS
zjv-, BOARD OF HE�Ar�LTH
... ............... .... OF .... . . ............................................
A. Appliratiou for Disposal Works Tonstrurtion 1krutit
Application is hereby made for a Permit to Construct (y) or Repair an
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IndividuaSew
age Disposal
S tem at* Zr.I M" a-0
I �c�. .ej
.. ........................................... I ........ ...
..... .............
Location - Address or Lot No.
......... Vk �__.5_,Lr ------------------------------------------- --------------------------------------------------------------------------------------------------
(�Owner Address
.................. ...................................................................................................
. .........
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--- i-ife A-
-ins a r Address z4 C
Type of Building Size Lot... -_._..I .. ��Sq. feet
Dwelling—No. of Bedrooms.--._._.. ............................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons._..._.....__-._....._...... Showers Cafeteria
Otherfixtures ..................... ....................................................................................
Design Flow .............. . 5 ....................... gallons per person T qay. Total ow ............................................ 10
4" Vjy 1 4
Septic Tank — Liquid capacity.19�9!�_gallons Length..._..._ ... Width;....-, .. 3�.. Diameter ................ Depth..._ A. -
Disposal Trench — No . ................ Width.... .......... Total Length ........ Total leaching area.. sq. ft
Seepage Pit No ... ................. Diameter.:!��- Depth below Total leaching area -A G10
Z Other Distribution box Dosin ta
Percolation Test Res Performed Date..........._................._..__......
4 U21z- . ..................... -f ----------- ( -------------------
04 Test Pit No. 1 ................ minutesperinch Depth of Test Pit.. --- A59,:_ Depth to ground water ... n9n& .....
Test Pit No. 2 ..... .......... minutes per inch Depth of Test Pit. -.._.N !'_
VSG " Depth to ground water ........................
.a ....... 11 ..............................................
0 .. F
Description of Soil ---......---•-• .............................. ... C .....%
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................................................... .......................................................................... 4 .........................................................................
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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate f Compliance has been issued by t�hoard of It
.'
Signed... ..... .......................
-C
Applicat' Appr ............................................. .... 71ZLI.0............
Date
Application Disapproved for the following reasons: .................................................................................................................
.........................................................................................................................................................................................................
Permit No....2.5 -7 1 f ZZJ.8 Date
.............................................. Issued_----- ............................
Dau
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... 0 F .....................................................................................
Trrtifiratr of Tomptiattu
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( )-6r Repaired
..................................................... ........... ........... ................
by ........ U ..... ef y ............. ............................... ............
Install,
at ....... I o-�- Z-7 Cc, ...................................................
............ .................... ....... ................. I ............................................
has been installed in accordance with the provisions of TI TR 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit ........... dated .... ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION. SATISFACTORY.
DATE... ............................................ Inspector.,_.r", -'`l _ ------ ...............................