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No......................... v u Fps✓..........—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
u6p�,_ /04t*j. _,, .............OF.. ... 4A--------------.-............................... r
aAppliration '-fur 43iiiVoo tl Works Tonstrurtion Vrrm t
1 Application is hereby made for a Permit to Construct ( ) or Repair ( ) an ndi . al Sewage Di spo al
Syst at: ----'—'
► . ...✓... ...-"--- -��.�r -tea a-- !
/, � Location-Address l or Address
W.
Lot No.
/ .......
-1. ••• ner
a � ...............
Installe Address
Q Type of Building Size Lot-.__•_____________________•.Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ....................
W Design Flow............................................gallons per person per day. Total daily flow---------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................
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 ( )
aPercolation Test Results Performed by------ ---------•---•-•---•-••- .........----..._..---------•-• Date---------------------------------------
a Test Pit No. 1----------------minutes per inch Depth of Test Pit--------.----------- Depth to ground water.._.__________.._.__....
�Tq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__.__._..__.________....
Ix ---------------------------------------------•----------•--•------•-•-•----••--•-•-•-•-•-----•---•--..........................................................
0 Description-of Soil---------------------------------------------- ----------------=-----------------------------------------------------------------------------------------------------
U ----------------------------------------------------------------------------------------------------------•-----..;------------------------------------...`-••--------••-----•-•........ •--------
W -------------- ------------- ------------------------------------------------------------------------------ ------- ---
- ---- -- -- - --- -
U N re of Repairs or A rations—Answer when ap ble._. .. _ _ o_Q a__ __ _: _
- -C GS rst✓--r Lac -------- -----
Agreement
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 J&-eh issued by the-board o health.
e
Sie - -— -------•-------
Date
Application Approved By....... --- -------- - -• . .-- :--------------- � - :" e-------
Date
Application Disapproved for the following reasons:........................ .....................................................................................
--.--------•--•--•------------------------------------- --------------------- ------•----------------------------------------------•---------------------------•------ ------------------------
. Date
PermitNo......................................................... Issued........................................................
Date
i
No.......•----..... .. Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f (, .............OF.. ..:�' . .............I..................-...............
Apli iratioo -for Ii.4poottl Workii Towitrurtion Vrroiit
I- ....•.•----
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an div'd al Sewage Dispo 1
Systpl')at
Location•Address or Lot No.____•______•____._._,+...................-.........."-8------•----
---•---------•------ -----------------------------------------
- - ------
W f,- gyp-caner Address
(� Installerg Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aq Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ----------------•-•--------•--------------------•- -------------•------ .---•----•--
W Design Flow..........................................._gallons per person per day. Total daily flow--------------------------------------------gallons.
P4 Se'ptic Tank—Liquid capacity------------gallons 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 Otl%er Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date-----•--.---------•--•-•---------.-----
# Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.--------.-_.__-_.-.-.
!� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water.....................
0 ----.---•------------------------------------------•-----•----•-••-•--------------------------------•-------------------------------------------------------
ODdscription of Soil---------------------------------------------------------------------------------------------------------- ------------------------------------------- --------- -------
U - `----- --------- ---------------------------------------------------
W ------- -- --------- --------------------------------------------------------------- - �, ., ._ ._ --- --_-------.-.--
. .. . - .. ---------•.-------------
V N ure of Repairs or AInations—Answer when .. . ....... . ..........._
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 bI564 issued by the oard Whealth.
Date
Application Approved BY y- .. ( /ff� .............. •.. y? -._...
Date
Application Disapproved for the following reasons-------------------------- --------------------------------------------------------------------------------------
---------------------------•-•--•--......------...---•--------....--••------•----•-----•--•---------•---•....--•--...---••-------•-----------------------------------•-------------------•------•--------
Date
PermitNo.--------............................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
O�
............................
Urtifirate of Ow"Umplianrr
Ste, fIFY, iat t2edivi ua Sewage Disposal System constructed ( ) or Repaired
by�. i/ .� r r" i
at` -------- - ---• f-----•' •----- - - r - --�40t -
--------•--------._......-•••-•-•--•---- - -- -- •
1has been installed in accordance with the provisions of : XISt to Sanitary Co/de as f�escr'b in the
application for Disposal Works Construction Permit No.- __--__. _ .---���q T1ted....../...�:._1--.._..�-_____-•-_•.--
THE ISSUANCE OF THIS CERTIFICATE SHALL, N . O 7 9"�J'�I) AS A GUARANTEE THAT THE
SYSTEM WILL FFUNCTIONJ SATISFACTORY. p�
DATE. �1.....- `� -_--_------. Inspector. - ---------- `
THE COMMONWEALTH OF MASSACHUSETTS
7G BOAR OF HEALTH
v0
No...--- _.... FEE...•-••-------•--•-•---
i >ol 1 k Loot rtirl - it
Permission is hereby grantedle - --- -------- ---- -=- _j------------------------------------------------
' to Constyatt ( Ar Repai ( an Indivtdu wage 1/S�'ry .....................................q�
2
at No.-.- � -'�C� -_--
Street
as shown on the application for Disposal Works Construction Dated.__ /_.�.__.-----________-----_.
Board of Health
DATE----- ------- ------------------_.....--•--•------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS