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App-Permit-Compliance
er No. -S)` .. �- �' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... .................... OF ..... .................................. F$s............. �.. Appliration for Disposal Works Tonstrur#ion jinmit Application is hereby made for a Permit t Construct System at Repai Ljr Individual Sewage Disposal .���..- .2. ... -.. -- - ... ---------•--•-•--------------- LQ.T..- C.1�23..-....m!.... .......---- Lo tion - ddress or Lot No. . ... ..... ._ ._ ...........-- - ......... ........................••... .......--•.................._........................ Owner 4Z Address ._. "!X1<- ............. .. ............... ------------------ -............................................................................... Installer Address Type of Buil ing Size Lot ............................ Sq. feet Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other — Type of Building ---------------------------- No. of persons ............................ Showers ( ) — Cafeteria ( ) Otherfixtures ................................................ -....................................... .................... ......................................... Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons. Septic Tank — Liquid capacity ............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 ........................ Description of Soil ---•---------------------------------------•-•--•-------.....--•---•--------------.....----•------•---•--•--•--------------------•-------...------------.............---------...------......--•-------- Nature of Rqpjurs or Al r do — Ans er en a licable._.. ......... --------------- ----...--- ----•---- "----%�---"-©-- -- --- ------- ---. ...���oa� Agreem t The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT!E 5 of the State Sanitary Code — The undurther agrees not to place the system in operation until a Certificate of Compliance hasgbnn ' sued4toZardhealth. ined- -t-. ..------•----- -----------------••-- Application Approved By..--- ................•---.--------.........----...... <1 . �1r ..... Application Disapproved for the following reasons---------------------------------•--•-------------•--•-•-------------------------........._........•••••....... -------------------------------------•--------------------------.......-•----............._..................-----•--- .......---.....--9,&-ic ............................ C� ate Permit No.- 3 -..__. Issued..._...... THE COMMONWEALTH OF MASSACHUSETTS BOARD Of HEALTH 14fh"./ji.....................OF.... .. � ' 11.(J .l (arrtifirub of Toutptiam THIS IS TO CERTIFY, That Pe Individual Sewage Disposal System constructed ( ) or Repaired (�)� by .......... f% ..----•.._. 15/. 1 �? ...... / f f Installer at-•-.---- -{ �._� ........l�` t 7_a +`'... ;-�-------------------------•-------------------•---------- -- --------•---•------•-------•- has been installed in accordance with the provisions of TIT r. 5 of The State Sanitary C9de as described in the application for Disposal Works Construction Permit No.___:_�-___-_� ____.-__. dated ._..CG. ..Z i- _K Z ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. -- } DATE.........~ -- . ...`,.... Inspector.../!.. -:-f r.� .. _ �� .............................