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THE COMMONWEALTH OF MASSACHUSETTS
BOARD �OF HEALTH
.....j....0.u?!J............... OF .........
1-•„�:�/M..Q.SJ7.T.....................................
Appliration for Dhipoottl i9ork i Tonotrnrtion Fermit
Application is hereby made for a Permit to Construct (Dg or Repair ( ) an Individual Sewage Disposal
System at:
•••....4J V.13le- :................ - ....... ........... e -D. -I........ ......................................
.. .
�ocation •Address •,�. or Lot
SRN .
.......-...... ?_------.... ` YY -------1./s' ...................... ...�. ��ifli!4 ! P 4 4.1i -I- _�-' �:....... .....
L Owner �, u Address
t3 S! fqM t. w
Installer Address
Type of Building Size Lot .....
�✓�,-,%..Sq. feet
Dwelling—No. of Bedrooms ---------------3 -----------------------------Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No, of persons.-...-.-----------------.... Showers ( ) — Cafeteria ( )
Otherfixtures ................. ____ ............................... ............................... ___ .................. ....... ..............................
Design Flow ........... �.,d�--....................... --gallons per person per day. Total dai flow..........-,...✓�.-✓-o.,........---.---gallons.
Septic Tank—Liquid capacityfODvgallons Length ... -��-`...... Width ..... `.7....-... Diameter---------------- Depth. --4 `
Disposal Trench — No ..................... Width .................... •Total Length .... ................ Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter ............. ___ Depth below inlet-.....-------------- Total leaching area .................. sq. ft.
Other Distribution box (V,) Dosing tank ( )
Percolation Test Results Performed by ..... -_LJ -L(- --/!QJ x Date ..z....�":-8.a-.........
Test Pit No. 1 .... ,-<--Z--.minutes per inch Depth of Test Pit .... 1-"... Depth to ground7ZE 0Z
Test Pit No. 2................minutes per inch Depth of Test Pit........-.-..---..-. Depth to ground wafilr,..,,-,...... -..-......
..
--------------„-„„-
-----------------------------,----,-,--,--,,,------------------------------ •-----------------------------------,,,---------------
Descriptionof Soil.....---..--5-��-.--.-...r&A%................. _.........-..------.-......----....--------------•--------.-.......----...------------...
Nature of Repairs or Alterations — Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed
the provisions of TITL S of the State Sanitary Code
operation until a Certificate of Compliance has be
Application Approved By...�
Application Disapproved for the following reasons:
Disposal System in accordance with
her agrees not to place the system in
............ I --/�
Tiratc --
Date
Permit No.--.-..a..�--��-------------------------_.
I Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD •'OF HEALTH
................... ........... .:.:........ OF ....... ......... ....... :c:....,.:`a:_.............-.................................. -
(9rdifiratr of. Timpliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O or Repaired ( )
by ....... ................
::.............................................................................................. ............................................................................
Installer
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Penmtvo..,,.::a....-
... :_a- ------------------ dated .... :................. :.........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE- ---•= ........................:: Inspector --...::r