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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.70WN.......... OF....y} s!Yr0 ()TN .. _...._.
Appliratiou for Disposal Works Toustrurtiun rrrmit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
,System at: j
.............._...L._ t= LZ!�( D k�l UL - ...-- ........
Location - Address or Lot No.
• ,13 tktyr_F41..... fox 1z73.....��7_..p�-.��vlr� �' 4xsL....°247-0
' Owner Address
zG
Installer Address
d Type of Building Size Lot _____..._ 4..............Sq. feet
Dwelling — No. of Bedrooms-------------------------------------------- Expansion Attic ( ) Garbage Grinder ( )
Other — TYPe of Building ............................ No. of persons ...... _________________ Showers
Cafeteria
Otherfixtures ------------- ............ ---------•-------------P--•-•----------------------------•----•------•----•------------------.....-------••.......(._-•--)--
W Design Flow ...................... .............. gallons per person per day. Total daily
W flow..____________ -Uv_ .------ gallons.
Septic Tank—LiquidcapacityldAvgallons Length_3-�__ Width_4�4!'_ Diameter_Depth_-
y_ --
x Disposal Trench — No_ ____________________ Width ................. ... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -------- !........... Diameter._Zn-?_/'/Depth below inlet --- (-._" __________ Total leaching area_Ze__'....... sq. ft.
Z " Other Distribution box Dosing tank ( )
Percolation Test Results Performed by.__C- .l"�_r�! .!________________________________________ Date____! . ..y
a
Test Pit No. 1l _IFM _minutes per inch Depth of Test Pit___ . ..... Depth to ground water__N�... IT
Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
a•---••---•-------•--------•--------•--•----••-•--•••-•••-------•...-•-•----•-•------•--••------••-•- .........................................................
0 Description of Soil-----. ....ro .T/Nc=..3% !/1/i� Nl� rylFl3/flnf• 5 '� .'rUb %—
2 4"__40 7 ...... 109,fori------------.................................................................................................................
w
UNature 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 sued 4y the board of health
3 _ A
Date
Application Approved BY . ..............---tea-- -•TJX-'
Date
Application Disapproved for the f oll ing reasons: ............................................... ..............................................................
-----------------------------------------------------------------------------................................................
Date
Permit No --------- �F�- S ��/�-------------------- Issued ----------12----Z =-----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ......
.........................................................................
Tntifirate of Toutpli urr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
r
by................................
11 j
Installer
at '
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ----------------------------------- dated ----------------------------------- �____..._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. `
TIA'r v A� ter/ Tnennrtnr / /J�/j9��r�.,