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No. � -- Finc ..I ................
THE COMMONWEALTH OF MASSACHUSETTS
_
BOARD OF HEALTH
....... ........OF......... Yl a .........................................
App iratiou for Bi ipoo al Warks Tonotrnr#ion ramit
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
2System at:
................... .
tion- dres
moo_✓ems Tc�s 2v s
.t/�r.... .as r�cJ As __.
W....................................•---••••------••-•--•------•-----...._......--•-•-•--•-••-•-........._..................
F a Installer Address
Type of Building7 // Size Lot ..__.G�..2_Jr--��---Sq. feet
U Dwelling—No. of Bedrooms ___.._....`�"...........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
P. 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 ....... ,1.......... Diameter.... . .. Depth below inlet ...... k;?�....... Total leaching area.3S9.t '�_...sq. ft.
Other Distribution box (x) Dosing tank ( )
'-' Percolation Test Results Performed by..��r?A'eT... ��� !.-- D. C='T°--------- Date___ __._____.
�a Test Pit No. 1..Z_...minutes per inch Depth of Test Pit ----- Depth to ground water._1__.
(% Test Pit No. 2 ---____•--__-_-_minutes per inch Depth of Test Pit .................... Depth to ground water ........................
W------------------- -------------------------------------------------------------------------------••---....-............................ ............................
O Description of Soil-- L--r-z`' - " c Sc./ . �----------------------------------------------------- ----------------------•---------
W
UNature 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 TI`:�
p 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 health.
igned. ------ -••/...e........
.............3a
Application Approved By-••------- ! Y ---------------------------------
Date
Application Disapproved for the following reasons- --------------•-------------•-------------•-------- ----------•----------------------------••--•••••-••-•-------
....-•-----•--••--•--------------------•---••-......--•-----•--•----•--•--•-•-•-•----•-----•--------• •--- ----------•-----•-------------•-•-•---•-------------•----•------•-•-•----------•--•----•---•---
Date
PermitNo ................................................---•-•--- IssuedL -------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
�rrtifiratr of T.nUt
plittnrr
THIS 4. TO,CERITIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
_._._ J .. ......... .. _
by
f — \ 1 taller
--c �...
has been installed in accordance with the p ovisions of TIT Imo/ j of dT State Sanitary Co , as espribed in the
application for Disposal Works Construction Permit No ......................... ...._...dated___._.._:' / ...................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C TRUE® AS A GUARANT HAT THE
SYSTEM WILL F CT N SATISFACTORY.
DATE. j -1 �............................................ Inspec .. .-- --- ...------ --- . -- --------.................................