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No.7.:f....... Fas..._:?.2 ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. OF. .........i.¢ ..1�':.!':.:!.4%I. d.l..1:4.......................................
Applirathm for Utripa,gttl Vurk,i Towdrurtion Vrrmit
Application is hereby made for a Permit to Construct (A,) or Repair ( ) an Individual Sewage Disposal
system at:klU
M;a 9 240
...........
- .._............................
canon dress or Lot No.
` Owner Address
W P�-,ei idd� 104 ,A11
p� Installer Address
6 Type of Building Size Lot............................Sq. feet
.U. Dwelling—No. of Bedrooms ............ 3...........................Expansion Attic ( ) Garbage Grinder ( )
"-1 Other—Type of Building No. of persons ............................ Showers — Cafeteria
Pt Other fixtures ....................................... .
W Design Flow..............5 &...................... gallons per person per day. Total daily flow .......... .aa.. ...................gallons.
WSeptic Tank —Liquid capacity1 :V_ .gallons Length,.E3'.L:_:.. Width..S.-'L L .. Diameter........,.`... Depth.5.`....'1"...
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
3 Seepage Pit No .... ...._(.......... Diameter ..... L ....... Depth below inlet......(:.'........ Total leaching area t i �.:.✓sq fr.eaNL�
Z Other Distribution box (CL) Dosing tank ( )
Percolation Test Results Performed by.........:.n�:............. Date .,.r: _.�®..:..1c:17
i.........
al Test Pit No. ......minutes per inch Depth of Test Pit_L Depth to ground water...' ...........
W Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
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ODescription of Soil ........... G --E- ..... Lr��Gil..i.............................................................................................................................
U..........................................................................---••---............------------------------------------.............................------------------•-*.................
W••••• ................................. ------................................------..,...,..---•-.--------.........--------...........-----.....---.................................................
U 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 by the boa • `of health.
�.� u
...
�✓ d... to
Application Approved By rr. rI/M!t��-' ... �✓�C? �}:.1�..
PP PP 1
Jnte
Application Disapproved for the following reasons:. ............... .........................._........--------........--------............................--•-
Permit No. a 7 �nv
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/Afro nate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...r.,..S..i.,.v..a.:'............................ OF....) It...'...1..a.`..f:t
.......................................................
Trrtifirate of TvmplianU
THIS IS TO CERTIFiY, That the, Individual Sewage Disposal System constructed (Px;, or Repaired ( )
has been installed in accordance with the provisions of TITI i l of The State Sanitary -Code as described in the
r
application for Disposal Works Construction PermitNO....✓...,:Ce.:...................... dated 'f C _. f '
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
Inspector