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No.- -- - -- Fla ........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Diapotial Work Tonstrurtion rnmit
Application is hereby made for a Permit to Construct
System at:
---•-•-_---•- .ct!;11� S moz� ---------------------------
--}•ML
-•---.ocat n�Address
.
Owner
.......... .. . .:.....� _ 1rY...............................................
Installer
Type of Building
Dwelling — No. of Bedrooms .............. ._._..._._......._.......
Other — Type of Building ---------------------------- No. of
Other fixtures ...................................
Design Flow ........... �AP........ ..................gallons per
Septic Tank —Liquid capacity.�!q�._.gallons L
Disposal Trench — No ................... Width...- ......
Seepage Pit No --------------------- Diameter .......... .........
Other Distribution box (� Do ing to
( X) or Repair ( ) an Individual Sewage Disposal
----•--•-•--••--- -LOTS S7 4 Sl A - ........ •..............
or Lot No.
------......• ...............E ^ -•• •------- --..... .._ .........-.---------
Address
Address
Size ......... Sq. feet
.-Expansi n Attic ) Garbage Grinder ( )
persons.1........................ Showers ( ) — Cafeteria ( )
?e on er day. Tjo daily fl .........�12........................gallons.
gth-$ at 4�_-10«.. Diameter---------------- Depth5.-4 .....
Total ength . .. ------- Total leaching area ..--------------- sq. ft.
Depth bel w inlet ................. Total leaching area .................. sq. ft.
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Percolation Test Results Performed y ............. D .... .......... ZH :-_�__. C ------------------ Date... �O -lz. - ��i__
Test Pit No. 1.. 42 ......m'nutes per ch Depth of Test P:t _A ........ Depth to ground water.... 41 .............
* Test Pit No. 2mi utes per nch Depth of Test Pit..... -------- Depth to ground water .--_ - �ZCl--._._.----
FQ�or1 k.o-rs
-------------•----•••••--- ------.........-----.........--•-----------.....--------•---------•-------•-....----------•-....-•----------......--------•-----
Description of Soil ............ et ........4 S T a S A Z 0- 3 6 T4LS
---------••-••---••••--•--•---------------•---••-48-- LSZ.. l_S�t"'n w ........................ -S '�� �.GR�--------- -••-•------------
STO at�5 ZZ- lg K, 5 10 .
----------------------------- ................... -••--------....... -----------------•---•........------......--•---. ------ --
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Nature of Repairs or Alteration — n w hen applicable.____ . . �.._........�. ... .�....__
..--• . = --------------------------------------------------------------------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of iT .a .
p} oz the State Sanitary Code —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued bYQard of health.
..
Si . -- -• ---_..... ..c . °--..
-- Application Approved B 11
_.. e
Date
Application Disapproved for the following reasons: ---•----•---------------------------•----------------------------------------------------------•----------------
..----------•-----------------------'-------'--------------._...------•----•------------•--......._.........-----------•------------ -----------------
D e
Permit No .............. Iss Led- t-...... __i_ _
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......G. L.. V �).�.-�.... O F. ................. C\/1�%C...... .............................
(irrtif iratr of Toutpliatta
T,� Is TO,, C�rRTI ,That the Indivi ual Sewage Disposal System constructed ( or Repaired
bY---------------
at-------��--•---�`� - .---- ---6------------ - �!-lt ----- ------------------------------•-----------------------------------------
has been installed in ace dance with the provisions of TI i I E j of The State Sanitary Code as des ri'bed in the
application for Disposal Works Construction Permit No ------- �.{_�-=�_QC(.------- dated ........ IZr^.��.-.�.�.{
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT "dHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector