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No......q_y. .... Funs..- I...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -OF HEALTH
.........OF....',� ..y --------------------------------
�3 Appliration for Mspmal Works C undrurtion Famit
Application is hereby made for a Permit to Construct ( ) or Repairs( ) an Individual Sewage Disposal
System at:
at:
• �"-` .. .. 'tF" P ......... �1............................................................ .................
.�� ati �dress �� o...............................i..
• .. ...---.`. .... ..x . � ... - ..��G-G�.-. ............
We
Address
a ............. ;, ---------------------------- --.......----------------------------...... --------------..........------------....---
Instiller Address
Type of Building - Size Lot.c 3`_3-�b_.__Sq. feet
U Dwelling=No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
P4Other fixtures ......................................................
W Design Flow........ ............... ........gallons per person per day. Total daily flow----- .4.'-75.......................gallons.
WSeptic Tank�—Liquid capacity/!l��gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width_......_. ._.______ Tot L-ngth.................... Total leaching area....................sq. ft.
v
Seepage Pit No..../-------------- Diamete?��'.��_ p"i be ow inlet.... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) /�,C d✓1 `�7�3 h 3
~' Percolation Test Results Performed by...4±70_'y0 ,,.--............................................. Date.......................................
,Wa Test Pit No. I................minutes per inch Depth ofl"Test Pit.................... Depth to ground water�_:.s;;.1..........
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
•-• ------•-••.............. --------------------•----------------------
O Description of Soil......./... ._. ....�k!&!Z�'.......... ........... ---------r � r �i'__
U
W
-------------------------------••-•-----------------------------------------------•---•..._......•••-•-------•-----------------------------•---•----------------------------•----------...........••---
U Nature of Repairs or Alterations—Answer 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 be n issu by the b d�of health. `
Signed. -- �'-"....==`-=.....`..._'--.. ------------ 1 Z3
Sate
Application Approved By...... ---- -- ... .... . ...... . ,--------- e ......
at
Application Disapproved for the following reasons__________________________________ _-.--.------------.---------------.-------------•-----------------
--•..............................•--..........---•....--•--------------.......------.._.......---•-------I-•---------........._...-----...._.......•••---•----------------.......-••---------•----.......
'�/ Date
PermitNo. -- ......................................... Issued---------------------------••-----•----•----------......
. ..
Date
No..... ., .... �} �F�$. ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEALTH
- 74��
..............OF.... �` .
. pphratio c for Mipmal Morks Tonotrurtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at �f
catr Ydddress ., r r No
...... ....... ......... ...L...��9 G Tf..... ..................... �k I ry C C•.:�]F`.... .�F.__ .... .. ...............
Owner Address
W
Installer Address
dType of Building,.= , , Size Lot. . �,.3. ....Sq. feet
V Dwelling. No. of Bedrooms................................ Expansion Attic ( ) Garbage Grinder ( )
........_
Other—T e of Building No. of persons............................ Showers — Cafeteria
0 Other fixtures .............
----------------------------------------•--------------------------------------------
W Design Flow......... .........................gallons per person per day. Total daily flow----- _d`" .......................gallons.
WSeptic Tank�-Liquid;capacity/ 'iygallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width._____._____._.___ Tot L gth..................... Total leaching area....................sq. ft.
3 Seepage Pit No.__. ..._...:. Diamete/ .... .. p e ow inlet................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) 3 � .
Percolation Test Results Performed by._2 u Mes
........................ Date........._.._._ ....._.._._..._.
aTest Pit�No:.1................minutes per inch Depth t Pit ..._.._...._...._ Depth to ground water.. OJ-_-__-__-.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a / e
..... --------•-------------- -
O Description of Soil......./-- -�tlt�-';����...... r ��-i ".,r
x
V -------------•-----------------•------- ........-•----•-•-•-........------------..............------------------------------------•-•-------•-----------------------------------•-------.
W ------------------------------------------------------------------------------------•-------•------------------------------------------------------•••--------------------------------------------------
V Nature of Repairs or Alterations—Answer 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 b n issu by the bgard of health
Signed. -........ ..... ''' ------------- ...7 .-.. 22
It
Application Approved By...... ---- .: .r�, •- ----- ...x! .
., t�V
Application Disapproved for the following reasons:................................. - ---•----.....------------------••----------••----.:....------._...-----
•-----------•....................................•-•-•------------.......•-------............-----------•--------------•--•-----••---------•------------------------•-----------------------------------
/. 1 Date
Permito.......... .......................................... -lisw.-,�......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD L H EA�T .. . ....................
..........OF..... . .. ... ....
atifiratr of Tomplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by.........h.....
'y........................................................................... ....... ..........
S-t-i.. ........ .... ...........................
.... ... ----- ... ---------------------------
.1 U
ei A' 4 . ....
has been installed in accordlKce with the ovisions o Article I of The State SanitaryCod as scribed in the
................. ol;
application for Disposal Works Construction Permit No. dated--2.- --1 . ...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A Cod as
THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ............................. ............. Inspector.......Z...................I.........................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF�H�EAH
No.... ...... . ...............OF..........A. . . ... ....... ..... ..................
FEE..../.. ....
Permission11 .........................................kreby 'granted............... ................................... ...................... .....................
to Constiue. o Repair, n Individual SPe isp. a rsken/),
y
atNo... ..... . . ........ .... ..................
t
as shown on the application for isposal Works Constructioq-Zermit% Dated..
4/................ ..................
;7
4'Boad of,
DATE._ .... . ................. .................
FORM 1255 HOBBS WARREN, INC., PUBLISHERS