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THE COMMONWEALTH OF MASSACHUSETTS
,.1�•- �jr'(� BOARD OF HEALTH
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............ fJ............. O F................Yke—. Qq 9j...........................................
Appliratiou for Biupoutti Works Tunutrnrtion Vinmit
�{^ ' Application is hereby made for a Permit to Construct ( )Q or Repair ( ) an Individual Sewage Disposal
System at:
.tet �o� �� to �� 0
....................................------------...... Go ..................
Location- Address or Lot No.
wr ................................Address
.............. .... � ------
Installer Address
Type of Building r- Size Lot.41.2�}:.Z.......Sq. feet t -
Dwelling — No. of Bedrooms._. ... ..... .............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .................................... ..................... - - ----------...------..............--------
(Z
Design Flow...............1� .....................gallons per p rson per day. Total daily flow..._. .... .5 �............ gallons.
tons.
Septic Tank—Liquid ca acit �V.. allons Len th�f.. a"... Width.�rit
P q P Y g g . c?..... Diameter ................ Depth.(._ :C3.::`..
Disposal Trench —:oto ..................... Width .................... Total Length .................... Total leaching area ...... ........ ...... sq. ft.
Seepage Pit No....... ............ Diameter.......). ...... Depth below inlet..... ........ Total leaching area..3.3 1'L -..sq. ft.
Other Distribution box (A Dosin tank )
Percolation Test Results Performed by.._..:`:..........}..0:....._y... ?::5 .:..................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of
Nature of Repairs or Alterations — Answer when
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE S 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 board Rf health.
Application Approved Bit".`. . _-
Application Disapproved for the following reasons:
!
Permit No...... -.� Issued ..... ..� .....4� oat`..... .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�v ��.� 'yl MOul tj
............I......................OF............. .... ...A........ ........................................
Trrtifiratr of Tompf attO
TH S T<ERTIFY, That the Individual Sewage Disposal S stem constructed ) or Repaired ( )
by......... 11��- t....4 ........................... .
TT
r_.has been installed in cc rdance with the provisionhe State Sanitary Co ie sc to the
application for Disposal forks Construction Permi' . ilie State
dated...... . t.�l . /
THE ISSUANCE F T IS CERTIFICATE SHALL NOT C TRUED AS THAT THE
DATE�-_WILL F11NC...47 ..FACTORY........ Inspec ..........-