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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® `°OF HEALTH
------=-------OF......,
, ppliratiuu for Bi-qVugal Workii Cnuutitrurtturt rantit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
r.
` Lo ation-Address r t No.
.. , _
ner A c�I : Address
......... . . ......•----...............------..:---•-•----•.
--------------_...........
Installer .
Address
UType of Building Size Lot............................Sq. feet
a Dwelling—No. of.Bedrooms............................................Expansion Attic ( ) Garbage Grinder (0
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
Otherfixtures ........ ---------------------------- •-•---•-•---------•---------- ------------------------------------------------
•------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capac'ity.ld?".,gallons -Length................ Width................ Diameter_._-_________-- Depth................
xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------,/-------- iameter.....J6.......... Depth below inlet....h.............. Total leaching area..- .....sq. ft.
Z Other Distribution box ( Dosing tank ( )
Percolation Test Results Performed by.... 9z._.__I yk.......................... Date.....Z!?Z.A� __11?.........
Test Pit No. 1________________minutes per inch Depth of Test Pit-----/1?......... Depth to ground water. .0 t-______-
r= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 --- - -- =---------------------------------------------•----__.............
_--_-----------------
---
_..........
------------------
•--___-.............. .
® Description of Soil............. - _ < ?
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.:TTL
p 5 of the State-Sanitary Code— The under ' further agrees not to place the system in ..
operation until a Certificate of.Complia a en is r hea -
Si .....--- :... ------•.. -- -----------•------••----------------- ................................
Application'Approved By - . • .` >� •-----. � J
. . ,,.. ---- -----
• - _ . - - Date
Date
Application Disapproved for the following reasons:..
----------------- ----------•---•---------------•-
r
--------------
Date
.`Permit No..--........................................ Issued--- _... ... .J' .
Date
8L.. Fps..... ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Oil` HEALTH
; '?. ...............O F......: '.✓mac<cssto
App iration for DiiiVniial Works Tomitrnrtion ramit
Application is hereby made'for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System.at •, ; _..,. ,: . �j�,�- I�-
f^ j� /�Lo�ation-Address t u,
.. 4.Q17.... ........................................... — ..N [Y!..t a .. •••
a - nor
Address
ALCA-.........�o.� ...-------- ---- -••-
.......
Installer Address
UType of Building Size Lot............................Sq. feet
�.. Dwelling—No. of Bedrooms-__..:......................................Expansion Attic ( ) Garbage Grinder 0jr-)
Other—Type of Building ----------------------------
No. of persons.........................--- Showers (` ,1...r Cafeteria ( )
04
d Other fixtures -- -------------------............----•-----•-••----
w Design Flow.......................... ..............gallons per person per day. Total daily flow.............................................gallons.
WSeptic Tank—Liquid capacity.-1� gallons Length................ Width.____.....'..__ Diameter---------------- Depth................
x
Disposal Trench—No..................... Width.... ............. Total Length......... Total leaching area.................... ft.
Seepage Pit No.___..._ _._ Iameter....__ __.__ De th below inlet.__.'_......__.. Total leaching area_.�w: ?____.sq. ft.
/- P .:
z Other Distribution box (L. Dosing tank ( )
~' Percolation Test Results Performed b . N. __..•................... Date-----, ...d?
Test Pit No. 1................minutes per inch De --h..r
Depth of Test Pit----- Depth to ground water.lw+P±!t4`--------
w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------------------------------- -------- -- -- --- - --•- ------------ ---------
O Description of Soil ... s---------•-e .'"'• .G° !L_---- !�` !
U
w
UNature 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'L-
p 5 of the State Sanitary Code—The unde further agrees not to place the system in
operation until a Certificate of Complia e a n is r h
Si --- _-.. ------ ----- -------------------------
Date
Application Approved BY .. -• .... !------. ..... ---•-- ........ .......
Date
Application Disapproved for the following reasons:......................................
..................................................
--------------•------------------•----------•-----•--------------•-----•-•-------•----•••-•••-----•••••--
Date
PermitNo.......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ' - OF..... .....
Trr ifiratr of f oMplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (t✓)r Repaired ( )
by.. .--•-------------------------------------------•-•-•-----------•---------.._.............---•••......--•-•-....-•----------
�'" Installer
-----------------
has been installed in accordance with the provisions o� 'rI" r j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit'No_ `f.--. 1................ dated------------------------------------------------
application ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....-•----._..1112- ............................................. Inspector.............Y._..._�------- ....•----......--•------------•----•-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,
f ! .•f•• c �:........OF....- c r?- ...............................
N •-•..... .............. FEE.... ---......
�i��u��1 ork� �on�� ion r�uti#
Permission is hereby granted................ ... ------•• -...........................................................................
to Construct ( �r epair ) an Indivld 1, Sewage Disposal System � ✓ f
atNo. ----••_...X ....__�.__Z4 ------- '._.d - ..............................................
treet
as shown on the application for Disposal Works Construction Pe mtt No Dated :_
k
ealth
Boa
DATE......
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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