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No. -_V -2-28L Fps .I-,� ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF ..........................................................................................
, pplirtttion for Disposal Warks Cha nstrurtion Vrrmit
Application is hereby made for a Permit to Construct
System at: 'J
16
Location - Address
Owner
Installer Address
Size Lot ---------------------------- Sq. feet
.................Expansion Attic ( ) Garbage Grinder ( )
No. of persons ............................ Showers ( ) — Cafeteria ( )
) or Repair ( ) an Individual Sewage Disposal
a T 5
........................................rnP- ---•------------
or Lot No.
Address
Type of Building
Dwelling —No. of Bedrooms.--........
Other — Type of Building ..............
Oth fi t
erx ures----------------•-•--•••-------•--••-•---•----•-------•---- --•---•-------••---•-•----•-----•---•-------•---•--.........•-----------------------------
Design Flow -------------------------------------------- gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank — Liquid' capacity.........._.gallons Length ----_-••-_-_-•- Width ................ Diameter--.----......... Depth ................
Disposal Trench — No. -------------------- Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ----_--------------- Diameter.................... Depth below inlet... ................. Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ........................... .............................................. Date ........................................
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 ........................
----.-•----------------------------••-••------ � ---- •-• ..... ......-- a.......
Description of Soil --- -OJ --•- --------
.............................................................................................................................................................................. .........................
Nature 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 TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
P P Y __•_ -.- • - -health.-
operation until a Certificate of Compliance has been boar o �-�---�-���--•--
Si
Signed.. - --- . . l-- ----•-•---
Date
Application Approved BY ��Z /----------
•-----•------------
�'�
Date
Application Disapproved for the following reasons-----------------------------••--------------••-•---------------------•-------•---------------------------
-----------------------------------------------------------------------------------------------------------••--•--------------•--•---- -----------------------------------------------------------------
���� Date
Permit No. - � 1-------------•-_------------- Issued----- �7 ---------------------....-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(Irriifirtdr of T.tirmptiFattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (� ) or Repaired
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-----------------------------------------------------------------•-•--------------•--
Installer
at. qtr a.;-` �=' , =,,w-•. �`--------•----------------•---------------------------••------...----•----••••--•------------•-----•-••----......------......_.....
has been installed in accordance with the provisions of TI i IE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._,, -?.%1-y1 .................. dated ---- E"...... ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B NSTRUE® AS A GUARANTE AT THE
SYSTEM WILL FUNCTION SYISFACTORY.
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