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NO / FEE
THE COMMONWEALTH OF MASSACH USETTS
-�' BOARD OF HEALTH
25 /A) OF Y�tn41011
vS Appliratinn fur Bhgirn tl el arks Cnnnutrurtinn tirrutit
Application is hereby made for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal
S stem at:
Y471441 67/77/ tlehili P6 4,011A4,
\TOSEPH L, j
Location Address or Lot No.
/ Owner Address
ril
to,
P4 Installer Address
Q Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms t Expansion Attic ( ) Garbage Grinder (WI)
p`'�., Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
a' Other fixtures
W Design Flow 5-.5" gallons per person_Per day. Total daily flow 2-2.e> gallons.
WSeptic Tank—Liquid capacity/QQQgallons Length..�7.- --.. Width--4.-tO--- Diameter-A.�-?.-.-- Depth-9---Q..-..W
z Disposal Trench—No. Width �..T,iQtal�LL n t11 Total leaching area sq. ft.
Seepage Pit No / Diameter .' l'')`" ...,,17eptl{beMFMet Z5 ' Total leaching area 261.4---sq. ft.
z Other Distribution box (V) Dosing tank ( ) p
'-' Percolation Test Results I Performed by.( WSP-D4---c Y)a.i i.J _`lr .- Date_.--:! 3-g
a Test Pit No. 1 5 minutes per inch Depth of Test Pit 1Z i Depth to ground water E•
r4 Test Pit No. 2 5 minutes per inch Depth of Test Pit ./f Depth to ground water f..sCen,ArTGi.t-Jj
0 Description of Soil 6/-36" terilw sva o- /O 2.41'-/O.,&,"/11 •) C - -- ?-4JJ
W 36"--/0" ^11C4' ° ^1.‘ 5 ''9-"D 1Qg' 12.0= 9 ' vN3SZr_j
x
'904-102," c c�y /40'.-/W. Sia 1',, ' /
Nature of Repairs or Alterations—Answer when applicable
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 of Compliance has been issued b the board of health.
Signed. ifiY.--71- kb// I
Application Approved By D64471.A..... Da,�Q
Application Disapproved for the following reasons:
® 2 a r,, Date
Permit No Yt l--sal�1 a" Issued. 10./ -�!"l
D
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OF HEALTH
71A/Ai OF X971,evi O`2/771
(Irrtifiratr of (Iuntplittnn
THIS IS TO CERTIFY, That the Individualwage Disposal System constructed ( kor Repaired ( )
by I allel
at o- - 44jotHttiiviedatifif
has been installed in accordance with the provisions of TI.T.,4S 5 of The State Sanitary Code d cribed in the
application for Disposal Works Construction Permit No Q'r'3. -- dated 16 f
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector