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KEEPING YOU ORGANIZED
No.10334
2453L
MADE IN USA
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�- 50
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEAL
...._... 6!/. ..........OF........ / V.!' '
ApplirFation for Disposal Marks Tonstrurtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( �an Individual Sewage Disposal
Systemat: p --•-•--••.•.... •-----•---••-•••••-•...............••---.
ocation-A ess or Lot No.
,1l�ct�t -----'--.........-•---•---••----- -•---••--•....................................
wner Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling- o. of Bedrooms_.........................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g ---------------------------- P ( ) — Cafeteria ( )
dOther fixtures .............•---------......_..---•---••---•--•--•----••-•---•-•--•-•-•-•-----•----.............--------••----•---...............---............••--
W Design Flow............................................gallons per person per.day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth....._...._.....
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...........'--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
1
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Pr' -------------
x
Description of Soil ---------•-------------------------------------------•--------•------- -
V --••••-•-•-•-•-•--------•-•--••---------------•-•---••---•-•-•-•-•--•---•••-.......•••----••••-•---•--•-•••-•-------•--•--•-•-•----•
W ---••--•-------------------------- ---------------•--------------••-•-•-----•-•---••••. -----
U Nature of Repairs or Alterations—Answer when applicable_. _:_ .A ,11J.7°".......&...........-_............
..------•-----------------•-•------------------------------•------------•--•---------•--•--------------•---...------------------•-----------......------...............................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ssued by the and h 1 .
D e
ApplicationApproved'By........... ............................................................... !-2-r ...........---•-- Date
Application Disapproved for th f llowing reasons---------------------------••-----------------------------------------------------------------------------------
....................•--•---------._._....-----•----••---...---•----••........•-•-••.......---•-••-•----------------•••--•--•-•-•-•--•-•-•-•-----------------------------••----------------••---•••------
Date
Permit No........... . o �-��'.�.:��..-----•-------•--. issued.------...�...----Z'.�.--•--$ -- .....--•---
Date
---------- ---
,n 1►
No........................ Fims...........
:. ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O� Fb HEALTH
Appliration for Billpasal Workii Tomitrnrtinn JIrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (e�an Individual Sewage Disposal
Systems t:
== .............................................. . •---------...------------------..... ----•-----.............-------•--......---
�r !11 yJ Loop cation-t dJd�ress ,y ,,�„ I or Lot No.
lf.3dJ�-,E :....er. tIj tf f; J .t� 0...._f .`� �1.............................................................................................
Vt Owner Address
Installer Address
UType of Building Size Lot.................... .....Sq. feet
Dwelling TNo. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ............................ No. of persons---.---.----................ Showers ( ) — Cafeteria ( )
dOther fixtures •-----•------------------ ------------•-• •----•--••••-•••••-•-•••-••-----•--------------•-----•-•••----••••-•--•••--•-•••••......•..............•-
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity. ..gallons Length................. Width Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter...................... Depth below inlet.......... ......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-- •------- -----•. •-••-------------•-•••••---••--•••-•••... Date........................................
aTest Pit No. 1................minutes per inch, Depth of, Test Pit..--................ Depth to ground water...--..................
wTest Pit No 2................minutes.per inch Depth of"Test Pit---................. Depth to ground water....................--..
------•.... •-•••••••-•--•-•-•......-•-•-...-•••--•----................................................O Description of Soil.... ay
'� ..- ............................. ------------------------------------------------------------------------------------................
l x
U •---- -•-•••-•----... ... --••-
W '' ...-....... -
r----------- a -
V Nature of Repairs or Alterations—Answer when applicablet :._ _'�'':/oV ------- .. ✓.2` j.-...�c�.... ' .0
._.. ��'
.............................................-.....................................................................................................................................................
Agreement:
The undersigned agrees:to install the aforedescribed Individual"Sewage Disposal System in accordance with
the provisions of'LITHE 5 of the State Sanitary Code- The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee.pf ssued by the-board of health. 1.
_ ... ..
Date
Application Approved By......... (•.. %" .. s� -21? —.Qx�------.
Date
Application Disapproved for t e- ollowing reasons: -----•--• `:--•-•••-••••••--•----•------...•••••••••-•-----•-•--•-••••••-•-••.................••••...
---------------------------------------------------------------------------------•-------------•-----------•••••--••••----••-------••-•--------••••-------••-•-••••-•-•• ...............................
Date
Permit No........ C� 5- e`-� -------------------- Issued.......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
` "
.... :. .........OF .... ... 3Zt .&/r,r
irat of Toutphaurr
THISIIS TIO ERTIFY Thaat the Individual Sewage Disposal System constructed ( ) or Repaired ( �.
by... YsLt.�! ..J, 11.l s d
r __._. ..__ ..............
9r ' r Installer ' +,j.. ---...----
has been installed in accordance with the provisions of TTZLF— `jAfv�State Sanitary Code as described in the
application for Disposal Works Construction Permit No._--.��_ff..--�� JJ _________ dated-. ...-.2 ....
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CON TRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUN T IOP SATISFACTORY
DATE.................... 3 i V.................................. Inspector------...
THE COMMONWEALTH OF MASSACHUSETTS
. BOARD OF HEALTH
`... . .``.........OF .....
w
'lion Permit
FEE...f" ... ........
Permission is hereby granted,.-- If.� !� .+'°✓As�,j�� ., ........... 1 .. ..............
..._ .-----
to,Construat ( ) or;Repair ( n In ivldualASewage01Dispos Sy tern
. 4
atNo..�-�r C -....................... _.. .......................................✓ S f",,��cr `
�p. ;,a treet . _
as shown on the application for Disposal;,Vhorks Construction Permit N4:S �-J.._ Dated-_el.
---•------------------•--•-•--••------•---••---------•---------••----•--•--•--------•---••---•---...---
DATE
Board of Health
'e--�g ....................... ------
FORM 1255 A. M. SULKIN. INC., BOSTON -