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THE COMMONWEALTH OF MASSACHUSETTS Fzz
BOARD OF !HEALTH
..............1..t�W�f1................ O F......V.e4r..b7047............................................................
Appliration for Disposal Works Tonstrixrtion fumit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
lc�xlttaW&................... ............... ... m'1gP ..'a
Location - Add ss r Lot No.
---• f3�o !.P.r!lrt_.:ssc........................................................ ._453 :&rz_Aftt._ ......................
Owner Addre ,/
,-a - - - -... - - ....... ----•- ..-- -•---- ••-h... -•..............
Installer Address
Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms -------------------------------------------- Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures -----•-----------------------------------••------- ._ . _ . .
W Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
,aa 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 ........................
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Description of Soil_____________________________________
--••--------------------------•-•---•--•••-••-••••••-----•------••---•-••-••--........---------•-•----•..._... •--------------------------•---..---- ll:.__----• ----•--•-••---• ----- ----
'71—
Nature
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Nature of Regairs of Alterations — Answer when applicable_]DIM _ X000 e j - jp�o • �Qt. -_-,
_.Q��-. •�..�?-_�- a _.... 34AW.AA.... r_r.iRd....................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z- 5 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 of 1Ith.
Signed.--• • ....... �P>aK.1.-Al�sdX?��--••---•--•----•••-•••••-••--•.. ---•t A'--jV.'Jft--•-•-----
Application Approved By ........ /O `1
Date
Application Disapproved for the ollowig reasons: ....................... -----------
......._____..
-•---------------------------------•-------...---------.--------------.....----------------•------._...--.--•--.............--•------------....__..... ....... ---------------•-•-•--•------...-•---
•'•-•-Date
Permit No.--------. - ._.... Issued_--------- `� Datc --
/v� t --------
20 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ..............OF..... P.r.►bio fL........................... ` ....................
Tntifiraft of Tontpliaxtrie
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ). or Repaired (- )
by-------------------------------------------------------------------------------------------- ----------------------------------------••••---------•-•--•----•----------•---•------•-•--••----------,
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 STRUED ASA UARANTE THAT THE
SYSTEM WILL FUNCTION SATICCAY.
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