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71
No.. tL(_.. FxE.....s.�-..................
THE COMMONWEALTH OF MASSACHUSETTS
SOAR® OF HEALTH
........OF...... —................� Jkppfiration for Disposal Vorko Tomitrurtion Vrrufil
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: f _
^\(^ 4_4 or Lot N -••--•----------------- --------
L Zo.c..(oj-.,Addr.e.
os
-O e Address
-------------••--•---...---Instaler Address
Type of Build' g Size Lot............................Sq. feet
U
Dwelling No. of Bedrooms----------
Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ________________•__________- No. of persons-_----•-___-__________----__ Showers ( ) — Cafeteria ( )
dOther fixtures,.._-----
w Design Flow...................•...Qo.. ------
ons per person per day. Total daily flow...... __ -___gallons.
WSeptic "Tank)-Liquid capacity_ __ -_ Ions Length................ Width-_.._-.-_.--_--_ Diameter---------------- Depth---__------_----
x Disposal Trench—No.____________________ VVi h___.___.____ otal Length.___.___-•- _ Total leaching area_______- __-_____sq. ft.
Seepage Pit No..... Diameter�V ;M th below inlet...._.I.__._.._ Total leaching are.t_....
Z Other Distribution fox ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date--------------------------------------
Test Pit No. 1................minutes per inch .Depth of Test Pit.................... Depth to ground water:::___.____-___-____.--.
�L, Test Pit No. 2................minutes per inch Depth of Test Pit.__..____..•........ epth to ground water------------------------
---- - --_--------------
........ .Description of Soil. --------------------------------------------------------------------
x
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 rees not to place the system in
operation until a Certificate of Compliance has been issued b he boar lth.
Signed
Date
Application Approved By------- ----=- - ----- --- ---- . • --. . ... ..... --- -------- F ---- ---
Date
Application Disapproved for the following reasons:--------•--------------------------- ----------•-•-•-••----------------•------------------------------------
-------•---------------------------------------------•---------------------------------•------------•--•-----•-•------------------------------------------•--------------------•------------------------
Date
PermitNo.•-----------• ---••-------•---- • Issued........................................................
____�`^--^-'----'--`_-_ ._- -------'----___ ---�_._'.._-..-••---•------ ----- ------------------------- Date --- - _ --- --- - --- _
--- Fps.... ....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
Application is hereby made for a Permit to Construct '( .) or Repair ( ) an Individual Sewage Disposal
System�at.
_ !Rc'aUlon-Address } o No.
l
�,. 6
e •O -� Address
W .
°'
Ins a er Address
Type of Building Size Lot____________________________Sq. feet
Dwellin No. of Bedrooms____._.____g Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------••--•--•----•-------•-•--------•--------- •----------------•-•--•----
W Design Flow_________________ 4°w`. 1 ons per person per day. Total daily flow..... __,' ' _-__-____gallons.
W Septic Tank-Liquid capacityIons - Length................ Widtli_._--_--. ____ Diameter....------------ Depth_...........
- -
-x Disposal Trench—No_____________________ Width......... = Total Length _-______ Total leaching area____ ____.___sq. ft.
Seepage Pit No_ ___________ Diameter ._ __. �flepth below ililet_____.._________ Total leaching area__,_ it-
z' Other Distributionjbox ( ) $osing tank ( )
aPercolation Test Results Performed by........................................................... Date----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit------------_....... Depth to ground water_-____-___--___-______-.
w Test Pit No. 2................minutes per inch- 'Depth of Test Pit...................... Depth to ground water---------------------
a - - ........................•• ------------------ -•-----........................................................
Description of Soil_______________.,/i : � _
U ---------- ----------------------------•------------------------------•--------------------------------------------------------------------------------
W
VNature 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 g ees not to place the system in
operation until a Certificate of Compliance has been issued by the,.board pf leqlth.
Signed r
«ram ` Date
Application Approved By------ � °---. ---- ------ - '
Application Disapproved for the following reasons---------------------------------------------------------------------------------------- Da e--------------
Date
PermitNo..................------- -----•----•----=---- Issued..................................................------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................................
T } TIFY��iat the Individual Sewage Disposal System constructed' ; or) Repaired ( )
a < nst s:. I alley
----•--------------_------
has been installed in accordance with the provisions of Arttc"le"XI of The State Sanitary Code.os described - t e
application for Disposal Works Construction Permit No............ ._ __ ' dated ____ _ -_
'
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 Q- HEALTH
�.�
NO ---•V a ...
FEs
'�n1� nrk4_un &rurttvn /rmit
Permissiori��or
reb ranted :.___ '
to Constr ct ( Repair ( ) an Wividu j Sewage j sposal. System
--- ---- --- - • .>.r fir- .-�----- �,,,- � '°""--- `� - tea..'-- - -----------�
.-.._. Street
as shown on the application for Disposal,Works Construction Permit No. Dated----/e 0
= ---------------
� f9 Board of Hea E
DATE........ �J '' � --------------------------• . .
y
FORM 1255 HOBBS & WARREN..INC �'., PUBLISHERS ,