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THE COMMONWEALTH OF MASSACHUSETTS
BOARD CfJ OFHEALTH
/.._.... Op` ..........................
Appliration foris.pos' ni Works (9vustrudian Frrmit
Application is hereby made for a Permit to Construct
System at:
do k cess �
................... .
..r ...... wJ--•.•%'..........
�.A ...................
Installer
) or Repair (�) an Individual Sewage Disposal
LUT -C13
Type of Building
Dwelling — No. of Bedrooms ........... ....................Expansion Attic
Address I
Size Lot ................---------..Sq
Garbage Grinder
feet
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ........................................_.................---------------------..... -------..................•-------.......................
.
Design Flow ................ ..ZA.................. gallons per person per day. Total daily flow ---------s �%----.....------....gallons.
Septic Tank—Liquid capacity/(,.?.).gallon Length ................ Width ................ Diameter................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length ........ Total leaching area....................sq. ft.
-- e
Seepage Pit No........../....... Diameter ........ r®........ Depth below inlet ....... ............ Total leaching area .�......sq. ft.
Other Distribution box ( ) Dosing tank ( ) 3a /o 0
Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch. Depth of Test Pit.................... Depth to ground water........................
Description of Soil—
..................... ................
oil—........-----.......................
.....................................
Nature. of Repairs or
when
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 heal
Signed.. liYl Y� sT4.....Z-1/ 1 ..........
i D e
Application Approved By... ........ ........ ... ..........2' ? rte`..........................._ 5.`� ..
Date
Application Disapproved for the following reason--s--:-
eatons:........................................................................................................--_
....................................................................---...................................................---------------------------.........•-----.............................._
Date
Permit No....ti J� :� .... _........... -- Issued_ ......... a a!a.._......-
Date
THIS IS TO
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trr#ifirtar of Tautphaurr
RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (-)'
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......:, :._%.:?..r ................. dated......"....:.::....7..... ...,.._........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....... ......... .--- 4.-- ........................... Inspector ._........... ... ......i:. ............