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No... FEs.......�o.._......_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH meg"
Appliration for Uispwial Wurkri Towitrnr#init 11rrmi#
Application is hereby made for a Permit to Construct ( ✓f or Repair ( ) an Individual Sewage Disposal
S stun at:
. �3.... „-o.......-.fit....ayN--
Location- Address
eS a, -T.... r ..............
Owner
...............................
Installer ,
_,,pr Lot No.
3.O �o. a e....I 7.... .6..... C✓M.._.
Address
Address
Type of Building SizeLot.....$: !`�....Sq. feet
Dwelling—No. of Bedrooms......r............... .-...... Expansion Attic ( ) Garbage Grinder (No)
Other—Type of Building 1!1R070-...:F.C No. of persons.......... La ............. Showers (S') — Cafeteria (i)g)
Otherfixtures .............. __ ........... ........ ---............ - ........... ........-...........
Design Flow ......... ........................gallons per person per day. Total da j� flow ......... 1110.0,_0...............ga ns.
Septic Tank—Liquid capacityt44@.gallons Length ....... >.... ... Width ............... 9b
........ Depth........
Disposal Trench — No__ ................ Width.....%.......... Total Length....-........... Total leaching area..o.;. _°......444t.'8
Seepage Pit No.......�............ Diameter.. .. !� sFept�i l)elow inlet ... 3 ..... � ��. Total leaching area.1.�'i .....6&,t4I t
Other Distribution box (✓� Dosing tank ( )
Percolation Test Results Performed by....L'bWMYV c...... . ............................... Date ......
Test Pit No. LAK ...Z ...minutesper inch Depth of Test Pit...._Ii.er. Depth to ground water.....^! ........
Test Pit No. 2.�
<.
-...minutes per inch Depth of Test Pit ...... 191r.. Depth to =round water ......... .W.J _.
of
Nature of Repairs or Alterations—Answer when applicable...... .......................F44.4S ..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has leen issued by the board of health.
Application Approved
Application Disapproved for the
'7 —e
Permit No..... . 2—L. --- --- ........................
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D.
THE COMMONWEALTH OF MASSACHUSETTS
c
�--^ BOARD OF HEALTH Pr c
.........1 C.!".%"'J.............OF....tr
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.......
................
TbFIS IS TO CERTIY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by ....... AL.L*e W. ......_ ...SMC-!.P..!k f -....-----•...................._.................._........
Yy .,e, Installer �•,/1� S V
at.----1:'.7k�,�.....-----• --...... .rt- -Y`....-•----'^ '- Install, 1,
!!cV:�?`.'.... J";!............
has been installed in accordance with the provisions of TITLE l of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ..... .-............... ..........._...... dated ..... ...........................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILLFUNCTIONSATISFACTORY.
DATE.......................................................... Inspector ..................... ........ __....... ......... ...................................