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No.. J�_.__ F>cs. 1.s ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
low. ...........0F..........4.. ..- - o --------------------------------------
App iration for Diapotiai Work,5 Tonstrurtion Prrmit
Application is hereby made for a Permit to Construct (9) or Repair ( ) an Individual Sewage Disposal
�j System at: , s
.. . �.....
W,� lLtca ' OwnAeddr �� tN-----------------------------------
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Lon
Y ----------------- o�p dress
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Address
Type of Building Size Lot __`3 a ----J - -- _._Sq. feet
U
Dwelling — No. of Bedrooms...._.__.4_
---------- Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
PA Other fixtures ................ .............. . .
W Design Flow -------------------------------------------- gallons per person per day. Total daily flow ............... _Ct__-4t .............. gallons.
WSeptic Tank —Liquid capacityZ gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No- •-__-_-•-______.____ Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter.-__IZSj__ Depth below inlet _._.:..__...... Total leaching area3s;?___sq. ft.
Z Other Distribution box 04 Dosing tank ( )
Percolation Test Results Performed b �7_ �. 04I 4 �_.. .. C ....___ Date___.?/<—/ _._,
Y-- _..
,aa Test Pit .... Z4......... Depth to ground water.__
Test Pit No. 1 ---- minutes per inch Depth of
w Test Pit No. 2 ................ minutes per inch Depth of Test Pit ----------------- ___ Depth to ground water____--__--•••__-__._____
- ....................... -.................. ------------ ,----------
Description of Soil .... ___�' �, _ sv�sai%
`cci.�ac.................. -------------- --------------------------------
--••-------------------------------------------------------------••--•-------•---•--•-•••----••-•-----•••-••--•-•-----------••-------••••-•-••-•---•••---••--••••••--•-•••••-•--•-------•--------•-•--
Nature of Repairs or Alterations — Answer when applicable................................................................................................
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'TTLE, 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.
G---------------------------
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Application Approved By__________________ _ �,si- � -G
Date
Application Disapproved for the following reasons: ..................................
................
Date
PermitNo --------------------------------------------------------- Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ................................ OF.....................................................................................
;'_
Tnxifiratre of TontpHatta
THIS IS TO CEI,TI�', That the Individual Sewage Disposal System constructed (>O or Repaired ( }
sta er j
at jl 1-:4 - ----•••------ 1/'c=
has been installed in accordance with the pr sions of TITLE. 5 of The State Sanitary Cod asdescribed in the
application for Disposal Works Construction Permit No... ...........
dal .
.... "..____.._________._.
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT
7RUED AS A G ARANTEE AT TWE
SYSTEM WILL FU CTIO SATISFACTORY.
DATE__..._.... ----------•-•----------------•--- Inspect ...
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