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No. � ... _.. Fps ............._...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
`/OF y�I/-�I%E��A�L/T�-H
-✓.-�✓"�k,/......------..OF..... X.� 1'•�'-6-•!O-, '217 ------------------------------------
Appliration for Disposal Works Tonstrurtion Frrmit
Application is hereby
Type of Building
Dwelling — No.
Installer
c) Construct K) or Repair ( ) an Individual Sewage Disposal
............... ....... 4� ......... C ....... — ------------------------
or I,9t
o.
,� '............. Cl. N/�'A��r-------------------------
1� A r s
s- ............
Address
rr�� Size Lot. . �.__ .....SI feet
of Bedrooms .............. .7_ ......................... Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fi tur s . ----------------------
Design Flow ---------- -.1_ ......._ gallons per peri da�. Total da}1}'ow.._---.._... gall
Septic Tank — Liquid capacit jgallons L gth.___�___ Width__. _/1Q�_ ._ Diameter ---------------- Depth_.
,Yf ,
Disposal Trench — �To.._._____!_.__-_--_-- Width .._.__. Total Length ........ .._. Total leaching area --- .'�_�._�_�?_sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ()O) Dosing t I t
Percolation Test Results Performed by ....... ?, 1� �� _ �yc pf! S Date------ 1
Test Pit No. 7.minutes per inch Depth of Test Pit...../ Depth to ground water.L/D.__----_____.
Test Pit No. 2 ........ Z --..minutes per inch Depth of Test Pit ..... 11 `.. Depth to ground water .....................
of Soil ----- 10!f t--- --
/7 _ il/1.4' 77 0 10
- /7 ® 3A "
Nature of Repairs or Alterations — Answer
....................
Agreement:
applicable-----------------•------------------------ •-----
.......................•--------•----------•---------------------
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'T'IE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bqpn issued by the board or health.
.. . ..•--.......................................................... ........... .
at
Application Approved —;E!-:: .....---...�...•--------------------------•--......•-•--•------... 1_..1_'- = ..
Date
Application Disapproved for the following reasons-....................................................... ........................................................
I Date
Permit No e�..1: �`7 -------------------------- Issued- -- ' Q U' ate 5
----------
Dat
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,�, ... �... rvt o v i �-
Trrtifiratr of Toutpliattrr
THIS IS__L:0 CERTIFY, Th� t,. 4dividual ewage is sal S7stem constructed
NJby ............. ----•----....---••---••----•----------•
�aller
w i \_ 1 1:1 / V l JCS
at. ........... `r' S-'
�or Repaired ( )
has been installed in accordance with the provisions of TITIE 5of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. ... �� - i ....... dated .......
."'_ _ -----------
THE ISS4ANCOF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE
SYSTEMA WILLF CTION SATISFACTORY.
DATE,------ ----- ----------------------------------------------------- InsDector..:.ILZ..__ = -•---- ..........--......----...-----•-----------•-----------
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