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No.._.15_----_-- Fus... v.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HE TH
I
•. ppliratintt -for Uiiviaiitt1 lVarkii Towitrurtilatt Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: r
-- - ----- ---••- ------------ e!�.........--•--•---.... ...---•----------- ..._.._ C _ _..-_
-.....
.�ion-� dress � or Lot No.
•-•--- --- -- -- .. ------. • •--•.............................. ----•--------- .D ...............................
ner Address
a ....>...... ------ --------------------------- -----------------------------
n aller Address
UType of Building � �� Size Lot____________________________Sq. feet
Dwelling—No. of Bedroom :`,.___ :'___ ___________________________Expansion Attic ( f Garbage Grinder ( )
per, Other—Type of Building No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures .._._
d _
W Desi n Flow._. ._.. .__ �allons per person per day. Total daily flow-------- -. gallons.
WSeptic Tank-/ Liquid capacity._.__ _gallons Length................ Width................ lliameter____....._.._.__ Depth.__..._.__......
x Disposal Trench—No. .................... Widt i.__.___ __.�__ l enWe
-- .--. . of eaching area.._..._._---..------sq. ft.
Seepage Pit No.____--)-__________ Diameter__ -_ w __________________ alpleaching area_.___.___._______sq: ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date----.----------------------------_------
,� Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water.._.-.-_.----_--.___..
fz, Test Pit No. 2................minutes per inch Depth of Test it.................... Depth to ground water-... -_-_--_-_.---____.
W
0 Description of Soil------------------- -------------------------•--•--
--- ------------- ------------------- ------------------------------------
x
Act
W
UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
---------------------------------------------- .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage D' osal System i accordance with
the provisions of Article YI of the State Sanitary Code— The undersigned furtl r agrees not to pla e the system in
operation until a Certificate of Compliance has been ' s d by the d of he
jigne •-------------
J %0y
Dat
Application Approved B /
PP PP y--• --�� �. ----•----- ... -. •-- ••---•. --- -----� -
ate
Application Disapproved for the following reasons--------------=-------------------------------- ---------------------------------------------------------------
•-•••---•---•••-•--------------•--•---------------------------------.._...•--•---•-•-----•--------.......••--------•---••••------•---....---------....--------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
'--- -----'--"----- ------------------------------
e _
f
r
��yy
No..... ................ Flz$.../,1�/..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD7
O HE TH
. ---- --.OF..... '�
................
Applirtttioaa for Diapntitt1 Workii Tomilraartion Vanift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: +�
-
tion dress or Lot I4 Q.
-----•--•------ -•••-------
.--- --••---•------ 04
••-------•----.
n r •- - --
Address
a -----
aller Address
n r
UType -of Building ySize"Lot_-_ _______.- _.-____Sq. feet
Dwelling_—No. of Bedroom _ ___ _ ____ ____________________-___-Expansion Attic ( Garbage Grinder ( )
aOther=Type of Building No. of persons____________________________ Showers ( ) .`Cafeteria ( )
d Other fixtures
-----------•----------------------------------------------------•--------- -----= =•=•--•------
W Design Flow.__ + --- allons per person per day. Total daily flow-------- _-___---___ �`�-gallons.
Septic Tank Liquid capacity? lions Length................ Width................ Diameter___-_- _...__ Depth................
x✓ Disposal Trench',—No_ ____________________ Widt I_ .___ 1 en ota eaching area__-___-__-_.......sq. ft.
Seepage Pit No______ ___________ Diameter__ ._ e e .w let____... __.._.____ al leaching area-__. __ _______sq. ft.
z Other Distribution,box ( ) I Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date-----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water---___-_.__-_____.___.
f14 Test Pit No. 2...........:_?__.minutes per inch Depth of Test it____________________ Depth to ground water-..---------------------
-
---' •--------- •----•----•-•-----•----•---•----•------•-----------------•---•------_-----
Description of Soil-------------------------------------------•--•-•-----•-•--
•
x
CU -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------W
U Nature of Repairs or Alterations—Answer when applicable._. ------------_--------------------------------------------------------------------- ---------
--------------------------
•---------------------------------------
-------------------fix=------------------------------------------------------------- --------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System ill accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to�pla}e the system in
operation until a Certificate of Compliance has been issued by th boaxd of health. 4
igned s +f ------- --------------------
Application Approved B f -- ---X-1-7--i
te
Application Disapproved for the following reasons------------------------------------------------ -------------------------------=-------------------------------
.............................. -•-----•---••-•-•----------•--------------------
Date
PermitNo......................................................... Issued...................................'....................
Date
rrt
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF—HEALTH
..:.O . .... ...... .. ...........
. �rrtifirtt�r rlf f�nrm�rlittnrr '
THI IS T RTIFY, hat the Individual Sewage Disposal System constructed ( �Ool Repaired ( )
by....... ----- -
at__... er Install
has been iri's`talled in accordance with the provisions f _ rticle I of ,The State Sanitary Co e , de cttbed in the
application for'Disposal Works Construction Permit o._._ __ dated
, roF...7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARANTEE THAT THE
SYSTEM WILL NC ION SATISFACTORY.
���
DATE___ = Inspector•- --=------ -------
C 91
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH `
/ !
....... OF d
N V440 �
4--
IN-spotiFal rk vnstryfjitoa Vrranif
Permission is ereby granted ------•-•••------••----•-
to Construc or parr. an ndividual Sewage D 4s -e
Sy m , ^
et
as shown on the application for'Disp.( Works Z/struction. Per if�o-----__ ___ _____ ted__J_. -.� - ._------------
:. ------------ _ ------ --• ------••-
YOBBS,&
Board of ealthDATE_... y----- - - - --------------t-
�FORM,, h21 `55 WAR.REN. INC.. PUBLISHERS -
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