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THE COMMONWEALTH OF MASSACHUSETTS
P1 �v BOARDS HEALTH
e� V.......-�D�IA��._...........OF................ . ..........................._....................
00 ,Applirtttion for Bigporittl Worki5 &,ittBtrnrtion 1rrmit
Application is hereby made for a Permit to Construct (xJ r WRepair ) an Individual Sewage Disposal
System at:
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\ . �' Location - Address or Lot No.
........., M _T ...................................................... ........................................--•---...--...--.........--..._._.....
OwnerAddress
............................................
�.q Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms .............._ .................... Attic ( ) Garbage Grinder ( )
Pa Other — TYPe of Building ........................ No. of persons ............................ Showers
( ) —Cafeteria ( )
6 Other fixtures .......... ................ ............................................................................................................................
�r� Design Flow..............�_10................... gallons per person per day. Total dailyy flow.............ZZ. 2.... ............... gallons.
Septic Tank—Liquid capacityiQLZI.gallons Length....Sd..C¢... Width ... 4..lQ... Diameter .... ....-- =..
�+ Disposal Trench — No. .... ................ Width ........1............ Total Length.................... Total leaching area .................... sq. ft.
3 Seepage Pit No ... Q..t, ?A2__... Diameter .... ..4........ Depth below inlet ...... 62........ Total leaching area..Z63.t g sq. ft.
Z Other Distribution box (K) Dosing tank ( )
Percolation Test Results Performed by......... .V,.=z..... ..4..: ........E ' ... Date .......:Z2.4 . .....
a Test Pit No. I ...... �Z...minutes per Inch Depth of Test Pit ...... 1. 1,5.. Depth to ground water ........................
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
on of
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Nature of Repairs or AlterAtions —Answer when applicable.....!.). c>
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 he undersi er rt agrees not to place the system in
operation until a Certificate of Compliance has been issuy the boarlCi,Q4Mlt ,
Application Approved By....
Application Disapproved for the following reasons:
Z 7 —TDtJ 89
.... ...............................
Z aze �
Date
Permit No ........... 4...l..._
e� ate
........................... Issued ..............?.,j ...Cl.:./.................
te
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� THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
.......................... ,! ...}.at'1.t.....
......................................................
hirdif rate of Tomplittnrr
IS I$ TQ,,CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( A
L"351I ..Cr ......................................................... .........................
has been installed in accordance with the provisions of TITLE of The State Santtlry Cnde as descF>be inIlte
application for Disposal Works Construction Permit No ,7,-2:. ,,11Z ........................ date............ .c
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL�'L FUNCTION SATISFACTORY.
DATE..... ...� ........ t....................................................... InspectorL-.....-......... ........... ............... -------------------.................