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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® LFHE LTH
...-..._..OF..-..- .. _ _..-_..._.... ..... - ..............
Applirati>o n -for 11-4pwittl 10orkii Tomi#rur#ion Vantit
Application is hereby made fora Permit to Construct ( ) or Repair Individual Sewage Disposa
S t at: )
---....----.
4.___ ...- .. . _� 4 4
_........................ ._._
ation-Addr or Lot No.
l��F���111/// - -- -.---•--•-------•--------------•----•-------------------••------------
er
..................•--.Address
nstaller J Address
dYP ..........................Sq. feet
T e of Buil �%/of
Size Lot.---------•------...
Dwellingo. Bedrooms...... .____. -------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------- �.���,p
W Design Flow__ ______ ______ __ �llons per person per day. Total daily flow.�_.....�:"�!-l�.• .._._.gallons.
WSeptic Tank Liquid capacitv � allons Length________________ Width---------------. Diameter---------------- Depth................
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_-_ _ _ _ _ ___ �-
a 71 /-•---- .
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..-.-.-----.----_.-. -_-
f� Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water_-.-_._---_----.--._.__.
•-••------ -
/ _L:,�
Description of Soil---- -------------� - ------ am ��
V -------------------------- - --------- •--- --- --• ----•-•---•. ••-••---------- --- ----
W ------------------------c" r --- --- �r
x -
U Nature of Repairs or Alterations—Answer when icable------_1s
------ ---
-----�-----�--"----�-�----------- •-- ----`` ----
Agreement: ----------------------------------------------
d �— 7/10��
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I 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 . .. --•--- -----------------•-•-•----------•---------------------------------
Date
Application Approved B �.
PP PP Y ...: -- a--------- . . .t 2
ate
Application Disapproved for the following reasons---------------------------------- ---------------------------------------------------------------------------
-----------•----------•-•-------•----------------•--•----------------•-••---------------------•------•---------------------•--------•------------------•--•----------------------•-•--------------------
Date
PermitNo......................................................... Issued-----_-------------- ................... ...........
Date
NO..A%. ------- Fsa....z .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
Appliratioo -for Biapoottl Works Tonstrortioo Vrrmit
Application is hereby made for Permit to Construct ( ) or Repair ('" ) an Individual Sewage Disposa
S ema }
........................ _A. .................................X-4------&:�;
ation-Add r s or Lot No.
......... ...... - =---- ----------- ..................................... .
W o ne Address
•
p f Installer J Address
d Ty e ofBuildi g 'Size Lot...:..............:.........sq. feet
Dwelling No. of Bedrooms.... ...... -------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building __--_-__---.____-_----_:... No. of persons.___-_-_________:-____.__-_ Showers ( ) — Cafeteria ( )
0.1 Other fixtures ---- -- ------- -------------------• -
d -==---------------------------------...----..-_tt -------
W Design Flow_ _______________ ____' ..'. ....._ .. allons per person per day. Total daily flow.""------2_6✓__ __e.__._gallons.
W Se ptic "Tank Li uid ca�acity allons Lent Width............... Diameter_____ Depth_._._____._._..
1 q 1 g h•-----------•- --------•
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 ( )
� f.Percolation Test Results Performed by......................................................................... Date::._ .. _- .
Test Pit No. 1___ __________minutes per inch Depth of Test Pit-------------------- Depth to ground water__--__..._.__--.__-____.
f� Test Pit No. 2................minutes per inch Depth of Test Pit--------_........... Depth to ground water--.-_--____--____-..-.
----------------- -- ......... ---...------------------..._......... '------••--•-.-----------
e
D Description of Soil____ _________
U -------------••---- -- -- --------- _ .......... •--- ........... . ..........
- ---- .... - -------
t fTf. � --------•- ----- -- •
V Nature of Repairs or Alterations—Answer when icable. ..... _ r :-- :-•-_ � h
-----
-------- •---•-•-------------------•---..._...----•----
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 board'-of health.
Signe . •........ ---•--•---•-.....-••-•-••------•--••------------------•---••-----
Date
Application Approved By------- r- ••. ---- - -- ---- .... ' •• ' .
_ ate
Application Disapproved for the following reasons:..............:................... ......................................................... ..................
•-----------------------------------••--•-•-••--.......-------•..._.......•--•---•---••------•------•--------------------------------------------------------------- ..................................
Date
PermitNo. -=---- Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ALTH
. .. ....:... ....... ... ......OF................ . - ...... ..!.-,--........................
Trrtif iratr of T""amplia-urr
HIS I1O CER- hat the In ividua ewage Disposal System constructed ) or Repaired ( )
by.. .......>
-------------zic----------------------------
Installer•
- ---- --•-- ---- - . ---- -•.--fly " .;
has be installed in ccordance with the provisions f Articl of he State Sanitary Cod as scribe in the
application for Disposal Works Construction Per No.,, . ---------------- dated + x`
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM'WILL FUNCTION SATISFACTORY.
DATE .............................................. Inspector.................................................................------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOA,RD,., -,F; HEALTH
No........ ........ FEE),,......
dip i otr�t tiiaa rr 't
Permiss'on is ereby d_ .____.-_- -+ ._ - - ..........................
to Aown
u ( ) r R ndi i S age Dist) ystem
af. --
Street
as son theta lication for Disposal Works C struction it No. .:: ed. _._ f
Board o Health
DATE-- •- ••---- _- -- --------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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