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No....11f7..... FE$ ...
THE COMMONWEALTH OF MASSACHUSETTS
0AR
11 '�` •`...........O F..... ... ............................
Apparation for %iVusat Workii Tonstrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System t: — ..? / — 2 a
. -- •. ° - --- ----
Loca Addre or Lot o.
* .Owner e. Address
a •---------- ----414.1-a--------------------------------------------- ....a ......................
Installer ss
Type of Buildijig� Size Lot____________________________Sq. feet
U Dwelling!—No. of Bedrooms__________________ __ Expansion Attic ( ) Garbage Grinder
Other—Type of Building ( )
a ______________ ____________ No. of persons_-.._...___.___............. Showers ( ) — Cafeteria ( )
a' Other fixtures _...
W Design Flow................ ;..._._..__gallons per person per day. Total daily flow.......` ____ __________-----------------gallons.
WSeptic Tank-/-Liquid capacit _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.( )
aPercolation 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-.._-..____--_______.__.
•-----------------------------------------------------------------------------------------------------------------------------------------------------------
Descriptionof Soil----------------------------------- •-------------------------•--•----------•---•------------•-----•--•--••----------•--..•--•--•-•------- ......................
W ----------------------------------------------- ----------•-----•---------------------•-•--------••-..._--•-••......••....•• --•--`--------- ......
V Nature of-Repairs or Alterations Answe when applicable.-..--.-: ------- ........ ________+ _
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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 boa ct of health.
Signed . -- . --- ---------------------------------
APPlication Approved By--:--- Lam• � � � .�� ��
Application Disapproved for the following reasons-....................................... •••••--------•-------------•----•••--•-•-----••-------------....
..............---------------------------------------------------------------------.......................................-•--•---------------••-•----••••------------ ---------_----------------
Date
PermitNo........................................................ Issued.......................................................
Date
w.r
No... Fiicu ..:::.....................
THE COMMONWEALTH .OF MASSACHUSETTS
BOAR® OF HEAL
..rx � ..'..........OFt...
Appliration for Utspviial Works Tomitrurtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at r. r, ,(
Z Ze.fn,
Z
e-'p,
.-L' _ a'. ,
q / L2----
Loca�6 Addr or Lot AT
n Owner Address
_ s
;.............................................• t'- �.7`'�,"4i,�._r•a_""-��--�a`.�.�,. �,x_..._r4,..�:.:-•fi�r.,,r�'_._.____.__.__.__.___
Installerdress
Type of Building Size Lot_______________________---Sq. feet
V Dwelling—No. of Bedrooms.'...................... ................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building . No. of persons............................ Showers — Cafeteria
a
d Other, fixtures ................................. ----------------------------------------------._..-..........
W Design Flow____________________._ gallons per person per day. Total daily flow._.:.__. _" .............gallons.
fYi Septic Tank A Liquid capacit r)' 01� r.gallons Length................ Width----------...... Diameter................ Depth----.--.--------
Disposal Trench—No......:.............. Width.................... Total Length.................... Total leaching area--------------------sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) ' .
aPercolation Test Results Performed by......................................................................... Date......................................
,4 Test Pit No. I................lninutes per inch Depth of Test Pit---...................Depth to ground water-----_---..._--_--.---..
f1 Test Pit No. 2................minutes per inch 'Depth of Test Pit.................... Depth to ground water----_---____-______--.-.
------------------=----------=---------------------------------------------------------------------.........................................................
0 Description of Soil--------------------•-------•-•----"---•---•-----•---....---•---------•--"------.;....-----------....................................---------------------- -------------------------
x
UW ---------------------------------------------- -------- -------------------------------------------------------------------=
Nature of Repairs or Alterations, Answ when appli ble._�,.. -� •__ _.. __ ____________ __
----------------------------------------------------- '` s -------
Agreement: "s�s
`
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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.
Signed --------------=- -------•---------------------
• .�!/� , ,r�.� ,e, Da+te
Application Approved BY a-- .r � # "
Date
��
n lication v 10 vi a reasons:------------------ ----------•---•---
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued........................................................
Date
THE. COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........OF. ... ...A... .... ..............
... ..
THI S EWER TIR47, That the Individual Sewage Disposal System constructed or Repaired
by----- e.......4------ --------------------------------------------------------------------............................................................
sJ�aller
------------------
---------------------------------------------
pith the provisions of Article XI of The Mate Sanit y C d described in the
has h*een installed in accordance 0 ey
application for Disposal Works Construction Permit No------------- —----------- dated_ -e -----
-- --------
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 O HEALTH
No. ...............OF... . ............
FEE-2---—-------—
!fz'
Permission is hereby g'ranj`te.dh...-..' 44 (,� --------------........... 4�...... - -------------------------- I ..............
o- onstrupt;, r �pa e is o . System t 'C o R'' an, Individual Sewag Di "Af.]
:2.at No.. V-
ri - t --n-----
A6 ..................
Stree
as shown on the application for Disposa( gra Works Construction P( lt No-lx Dated____ X- ..........
. ..`...sue_.
.......................
Board of Health
DATE...
--X- 1- 7-1-----------------------
FORM 1255 ORBS &-WARREr4.' INC.. PUBLISHERS