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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. ... ... .............._.....O F ..................................... __1 ..................... .........................
Appliratiou for Disposal Work.5 Tvuiilrl!r#'" Vrrmit
Application is hereby made for a Permit to Construct or RepairIndividual Sewage Disposal
System at: Kl I -D � _d
S_.::.�_T......_.
................ . ....... ...........
Location - Address
.................... . . . . ...................... I .................. ......................... ......................................... --...-------•-----..._..._-----
wney
. . .....
Address
.................................. ------------------- ..................................................................................................
---- 7Z �'-Installer Address
Type of Building 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 ................ minutesperinch Depth of Test Pit_..___._______._.___ Depth to ground water__.___._._._..___._.___.
Test Pit No. 2 ................ minutes per inch Depth of Test Pit______.___________._ Depth to ground water_._____...___._.__.._.__
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Descriptionof Soil ------------------------------------------------------------------------------------------------------------
................................................................................... ....................................................................................................................
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Nature of Repairs or Alterations — Answer when applicable.__.___ ..'7 ... / ......... I ... -
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T LE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is�uedby the board of health
Signed.---- X=LZ4 - ------ -------------- .. .....
Dag
Application Approved By ...... (::)U!CaA ..... . ...... 7 ................................. ....... --- �s ..........
........ .....
Date
Application Disapproved for the following reasons: ................................................................................................................
Permit No .... _�_S_-i - ------
.............................................................................................
Date
Issued -----4t 30185
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Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................`...I—,........ OF ...... 1 .............................................................................
I
(9rdifiratr of Toutpluturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
.. -
by .......... ; . . .i ...;
..................................................................................................................................................................................
Installer
.. .......................
at .............. ... ;..,. —
....... .... ................................................................................. ............
has been installed in accordance with the provisions of TIT,r--F, 5 of The State Sanitary Code as described 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 FUNCTION SATISFACTORY.
DATE. -
........... .......... .............................................. Inspector-------.--'---=-------------------•-----------------------------------.........-•--