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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... ......._............--......OF..........................---...........------------..........-----.......................
Appliratiuu for R -spots al Workti Tomitrurtiuu thrutit
Application is hereby made for a Permit to Construct ( ) or Repair (/an Individual Sewage Disposal
System :3 �T2 ►" LOT N I 2 31 VAP �- __ _
..........................
- .... • --•---......, .............................. ....... -----------------•-•---•----"-----------•-•---- .°� .........
oc on.
. Addre s or Lot No.
rs 'i1� A-
........................................................ S .....—.._.......-•----------------•---------- ------.
Owner Address
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ........................ .... .............. pansion Attic ( ) Garbage Grinder ( )
p., Other —Type of Building ........................... ersons ............................ Showers ( ) — Cafeteria ( )
P-4 Other fixtures ------------------------------- _ .
W Design Flow -_• .........................................gallons r erson p day. Total daily flow ............................................ gallons.
W Septic Tank — Liquid capacity ------------ gallons L ngth------- _________ idth ---------------- Diameter ................ Depth ................
x Disposal Trench — No ..................... Width_._............... Total Lengt .................. Total leaching area .................... sq. ft.
Seepage Pit No --_----------------- Diameter ................ ._ Depth below inlet ..... ............. Total leaching area ........ .......... sq. ft.
Z Other Distribution box ( ) Dosing t nk ( )
Percolation Test Results Performed by .......................................................................... Date .................................... ..
aTest 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------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------•------------------------------------------------------ �J
Nature of Repairs lteration� — Answer._w n a licable ________ -----------------------------------------------
Nit
______...._______....._ ......_..._...__._._..
°� j�
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE, y g g p y
of the State Sanitary Code —The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued�by the board of health.
/1 / > / i)
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ate
Application Approved By ... ---•- •. ................ ... ....... .. ........ .........._----------------------- G%���
D e
Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------
-----------------------------------------------------•-•----•---••-----------------------------•----....--------•---•-•-•-----------•--•------------------•----•-- -----•------....----------•----------
PermitNo........................................................./v
Issued ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................................r..... O F.....................................................................................
hirxii�irtt#�e of f�uut�rliunrr
THIS II�EY, That the Individual Sewage Disposal System constructed ( ) or Repaired)
by
Instal
has been installed in accordance, ---------•- �--------------------- --�-----------
�Sanitary
- • -------•-_-•----------------------------
e wi i the provisions of TIT Z , j of The S to _Co asd scribed in the
application for Disposal Works Construction Permit No.1'-'__1 ____ dated_y_._,l_c�!'--------------------
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A ANTEE THAT THE
SYSTEM WILL FUUN TION AATISFACTORY.
DATE----------------•-.-.f ............................... Inspector.... ...... ........... ----- .............................................