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Nol l. 273- FSS...... �_.��..........
THE COMMONWEALTH OF MASSACHUSETTS -
BOARD OF HEALTH
T 17/�
Appliration for Disposal Murks Tunstrudion rami#
Application is hereby made for a Permit to Construct
System at:
.....-----.7... -- le w D .................
�- cation - dr s
Owner
Installer
Type of Building
Dwelling — No
Other — Type
Other
( or Repair ( ) an Individual Sewage Disposal
� y 2....�,� ?.Jin.
T Q -.._................
or
......-----sIL:- ---• .................•.-
Address/
.... - ---------- ----
Address
Size Lot S fe t
-----------•------•----•--- - e
of Bedrooms .......... 02 q
............................Expansion Attic ( ) Garbage Grinder ( S
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
fixtures..............................................................••---•-•...-•-------------
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid ca.pacityZa'!?.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 ........................
------------------------------------•----._...-----------•-------•-•---------•--•---•..._._..._..........•---•----•-•--
Descriptionof Soil........................................•------...-----------•-•••-----..._._....---•------------------•----......._•-------....---
-----------------------------------•-------••-•---•-----••-•---------•-----••-.
Nature of Repairs r Alterations — Answer when applicable_.__ "S �A..l._.___ ____ __________ __________'_� ....j......_..
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Agreement: a J&_ l ser*c Ten S, — 3 r lc9-w w ;M-3 °Sir
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
operation until a Certificate of Compliance has beeni ued by the boar iea /
igned.........
Application Approved By--__...... D e C�
Application Disapproved for
Permit No..• -•f"3-------------------------•---•-•-
-D e
Issued- ------------- •--•---•
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD/ OF HEALTH
...........OF....::f..�..�`. O v % ,Z
..........................................._...................
(9rrUfirate of Tunt1dittnrr
THIS IS TO CERTI Y, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by-.%'� lid - s -
.__-----•-•------ ...
•—� —�•- /�' Installer
at ( f7"�. __. E... w.4 -.D-"......---- �L....................../ 2 .1 1? ori-:nft�
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 ------- 9_L.7-_3 ............... dated__.._4_.�$�T .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEk WILL FUNCTION SATISFACTORY.
DATE.--• ....... Inspector_?Ly Sn.Gbf.SNjcG¢�£ 9:..�_.t...............