1378 Application & Permit 1993 w
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_ "O \ THE COMMONWEALTH OF MASSACHUSETTS
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a BOARD OF HEALTH
a ,i � . _ ) CIT/ OF A/oic7 mM�k
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(� :. 'cation is hereby made for a Permit to Construct ( ) or 'epair f)� an Individual Sewage Disposal
System aka. DM 0 S vvews 3
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maauer Size L: as, ,_y
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U Type of Building uu Size Lot..Q' 77 [eet
Dwelling—No. of Bedrooms T Expansion Attic ( ) Garbage Grinder ('7
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Other—T e of Buildin .5/"/C&.. ._A,mab o. of ersons
W yp g f' V p .B Showers ( ) — Cafeteria ( )
d Other fixtures pp..y
Design Flow Sr gallons per person per day. Total da'y flow Lfl.� gallons.
W Septic Tank—Liquid capacitvica/gallons &ength. Z4' Width..0 _e" Diameter Duel 6-",3"."
x Disposal Trench—No. 3......... Width 3 Total Length 3J A Total leaching area_.:./......sq, ft.
• Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
z Other Distribution box ( rte Dosi ( //I' po p
a Percolation Test Results Performed by �Al C I4414L,�+NNLC Date Z—I °93
,.l Test Pit No. I minutes per inch Depth of Test Pit...s Cv" Depth to ground water /UUAIp
W Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water /t/C44/�
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Description of Soil �.� - �r✓.S UI (. - C1jmP- S.C.%� �NE �/!w!'
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Nature of Repairs or Alterations when applicable �- AI Li N
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Com liance has been issued by the board of health. ?
Application Approved By r.4.. .t_Ece_—'_r /U' —/t-SJ
Date
Application Disapproved for the following reasons•
Date
Permit No Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ... ... . ....... .. ...
Tertifirate of Tumplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.
No
flthpnnat lIInnstrurtinn jrrmit
Permission is hereby granted ' ''`
to Construct ( ) or Repair ( ) an Individual Sewage,Disposal System
at No ' • seem
as shown on the application for Disposal Works Construction Permit No r..__:5: Dated
DATE
FORM 1255 A. M. SULKIN. BOSTON
Board of Health