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No. ./76 Fa$.... 5—
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
70R 11_l
................ .............. OF......y
A. Tt __.....
Appliration for Disposal Works Tonotrurtion jinmit
S stApplica.tion is hereby made for a Permit to Consstru�ct (A/) orRepair { ) an Individual Sewage Disposal
--Y 1< .......... /...c.1 _ � --- � %lam
- ._.... ...
..... - ......... ........ -�`r �l�MoCo�
Lot No
Owner Address .....................
-.••••'
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Installer Address
Type of Building Size Lot.A�21_dIVV ______.Sq. feet
Dwelling —No. of Bedrooms.__._...___ ...__....Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building .1 L No. of persons..._ �................... Showers
( ) — Cafeteria ( )
Other fixtures .
Design Flow ____----.-. _----------------------- gallons per personrper� day. Total �ia'1 flGow------
!S g j y �-----•-•-----_---• glonss
Septic Tank — Liquid ' capacit/Z allonx 4ength_._...-.6 ._ Wi - ;7,o Diameter---------------- Dept1 --- (� -..
Disposal Trench — No ..................... Width .................... Total Length..__. .�....__ Total leaching area -------------------- sq. ft.
Seepage Pit No ----_-------------- Diameter .................... Depth below inlet ....._..._....:..... Total leaching are 5/ q. ft.
Other Distribution box ( ) Dosin tank
Perco tion Test Results Performed by. �.x.._C. ............... Date.... ��/
y.
T st Pit No. 1 .----....minutes per inch epth of Test Pit .. ............. Depth to ground water.._.. - /x .--_
T st Pit No. 2 ----------------minutes per inch Depth of Test Pit .................... Depth to ground water ...........
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Description of Soil �------� `S`3Sc21G - `L!/(l ViY�rJ�
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ature 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 TIT IE 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. j
Signed...).1_\u ► c a ���. ' l [ f
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Ce+.s-c =.i ✓�� Date
Application Approved By... -- --••----• ...............
Application Disapproved for the following reasons: .......... .......
Date
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_
Permit NoDate
. � � - IssuecL. `� ,P
yak-------- -----••---•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF* ............................... f................................................
Tntifirab of Tontpliatta
TH-IS IS-.T..OCERT--PFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-- .=--------------------------------•---•-----------•-•--------•--------------.......------•-----............_..........--__...
i� --Installer
at
has-been installed in accordance with the provisions of TITLE 5.of, The State Sanitary'We..a-escribed in the
application for Disposal Works Construction Permit No ......................................... dated .............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL, NCTION TISFACTORY.
..''"9�
DATE.. �� ...... Inspector ------ -------------------------- •............................