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No.. 1....7:
ES...—...... �.. �.....
//"-) THEBOARDF HEALTH ALT FMASSACHUSETTS
JFV-It ---.--..--.OF...........................................•--------------................._........
Appliration for Ui�po l Works Towitrnrtton 1hrmit r -�P 1C
Application is hereby made for a Permit to Construct ( ) or Repair (X an Individual Sewage Disposal
System at:
........ = . � ......------.....SI A C OA16 --------. �-�'-1 6E. ------
....._-------------------
ion q
---- - �!-
Locat- ss �y I of No.
�' p1wner dre$r,.�
C jWV -- -.-- •- ------------- ----------- j'....a�[J
Installer X ress
Type of Building -7/ Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons -•__.-__-_____._.-__-______- Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------ ----------------------------------------------------•-•----------------------------.........---
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 ........ _._ f--__. Total leaching area .................... sq. ft.
Seepage Pit No ---------- .r _.___. 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 ............ ... imutes per i Depth of Test Pit . water--_-....'.'
�.t- . ........ .......... w ...............
............
Nature of Repair or Alter s — Ans when ZU
26
The undersigned agrees to install the afor
the provisions of 1I TLE 5 of the State Sanitary
operation until a Certificate of Compliance has be
Application Approved By.
Application Disapproved for the
--------A
s•
juin accordance with
to place the system in
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Date
PermitNo......................................................... Issued .......................................................
Date
"PSE COMMONWEALTH OF MASSACHUSETTS
BOARD,, F HEALT
..........................................OF....'� . ...:�........................................................
Trrtifir .r of flontplianrr
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; j 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.
DATE................................................................................ Inspector--------------------------- --