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THE COMMONWEALTH OF MASSACHUSETTS
BQARD OF HEALTH
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� ► alirtt ivaa fur Bi,_qVu_q a1 Wurk,q TunuUnrtiun Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S stem at f q�yq/p /AZ
J��� /I .01 J I /� tom/
> Location - Address r or Lot No //
cr _ 'lddress
...a........... .
�r ;� 1.�0... .... ..�3...4. ._ I ---�-e ' C t' J j, u�.r2 - rr.7.R J : .
�.• htstalt<r Address
Type of Building Size Lot__._..e/`r_°_ �..Sq. feet
Dwelling—No. of Bedrooms....... ? ..................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building �b1.&".L?._e'.r•. No. of persons .......... G............. Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow ..................? 5...........,..,.,....gallons per person per day. Total daily flow......... 2!;�........................ gallons.
Septic Tank—Liquid capac>iitylee�....gallons Length_&'..'Lt..... Width._y .... Diameter........'........
Disposal Trench — No.._N(.?3 ....... Width ... Total Length...........— .:.. Total leaching area .......—:.......sq. ft.
Seepage Pit No .......... I......... Diameter...../.;?:.......... Depth below inlet ....... .......... Total leaching area... Y ..... sq. ft.
Other Distribution box (t/S Dosing tank
Percolation Test Results Performed by.....I f ??v t ?.._....................... . ........ Date...... / f.(..t'..7............
Test Pit No. 1,.—L27 per inch Depth of Test Pit.... ..... Depth to ground water...! .........
Test Pit No. 2..: �._gc....minutes per inch Depth of Test Pit .... .`........ Depth to ground water....'.`. 'v8rp ........
Description of
Nature of Repairs or Alterations — Answer when
undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
ions of TId3 Sof the Stat anst Co e — The `n2ler�ig� ed further agrees not to place the system in
until a tificate of Comp ante has be , issued by the
Signed.,F �i.0 3z., -- .. {
s ..................... .......... .. ..............
,n of
By----`- . --/r$-f.:!l-'� �-------------- ......._------------------- ...... QI ��.4.(n2 ...........
Date
Application Disapproved for the following reasons:
Permit No.. ��`-4------------------------------
THE COMMONWEALTH
Date
Issued .....r U�%1 Rr_%S�-----------------------
Date
MASSACHUSETTS
OARID HFALTH/
of Tour l$iFanre
ewage Disposal System constructed ( Lo�`or Repaired
has been installed in accordance with the o - sions of TIT. 5 of The State Sanitary Code as described in the
p} Y
application for Disposal Works Constructi Permit No._. ................ __ ------ ......... dated ............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.ZZ:,--A(m-�----------------.................... Inspector.; / ..... y...... ...1�%��/�� - ---------- ----