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1-.
No _... Fxa....Xr� ...
THE COMMONWEALTH OF MASSACHUSETTS
�� AR® AL. H
............ ...O F...... LX ,,,
ApplirFation for Mipas al Works Tnnstrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
� ............. 1
� ] je /Z ress or Lot No.
�� ner Address
..............................................Address
.
M Installer Address
Q7i Type of Building ;- Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms...___ Expansion Attic ( ) Garbage Grinder ( )
a`L4 Other—T e of Building ._...___.... No. of persons............................ Showers
YP g ---------------- ----------- --�- ( ) — Cafeteria ( )
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........................................
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 Description of Soil.......................................................................................................................................................................
U ---••---••-•-------------••-----••••-••-••-••-••••••••••••-••-----•••-••-••-•••-••••............-••--•......•............................................................
---------••.... ..............
-------------------------------------------------------------------------------------------•---------••• -- -•. --- -------- . ................ ------------
U at r of Repairs or lterations—A wer hen p livable. -- ------ - � ---- --.. -----••-----.
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste n accordance with
Tr1e-�
the provisions of T'T.! - 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beenf issued by th&board of healt
Signed-- "2F--• ....... . ..... ..X............. ...�/7-
Date Ir
Application Approved By__ __ ___ _________ .........
•• ........................................
Date
Application Disapproved for the following reasons. -•-••...--•-••-•--•••••--•••••-••---------••-•--••••••----•••-•----------•••••-----•-•---•--••-----••-•--•-•-
..•••-•••.......•-•-••••----••••••--••---•••-•7..•-•-••--••••••• •------•--------•------------------------ --------------------------------------------------------------
� Date
Permit No....
- --------------------------- Issued........................................................
Dat..
N ... -- Fx$.... .......
THE COMMONWEALTH OF MASSACHUSETTS "
BOARD OF HEALTH
....... .. ........................OF.....................-....
Applirafion for Disposal Works Tonstrur#iuit Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: • Ct ---/ '
- ------------
Loca dress or Lot No.
..!_ f .! ... ..
` J ti O ner
a u � - Address._.._..
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms-__--.S. - ---------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
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........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------_................
a •-•••-•--•••------------••--------••......----••-•-•---•----................................................................................................
0 Description of Soil........................................................................................................................................................................
x
W ---•••----------------- . -- --- --------.--
U atur of Repairs or Alterations—An wer hen p licable -� Pd �_ -.r.____ � �'_______ __ ____
'' �'`Z'
Agreement r
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste n accordance with
the provisions of T I:Li:
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the boar of I I ;
�y /r Signed. ._ _ _._ r A --- ........ --A.............. ---�=---�..���•------
f Date
Application Approved BY--- --•- ..._Z�... ........ ' "-- `............................ Date
Application Disapproved for the following reasons: ..---•-----------------------------------------------•-------------........................................
.....................................a..-
Date
PermitNo. -----------=- -- --------------------- Issued.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH,
..........................................OF...: .✓.....d.t!...�::� ....... .LJ
(9rdifiratr of .To.mpli.aur�e LA&W
THIS S E ,ITI Y, That the Individual Sewage Disposal System constructed ( ) or Repaired (� }
bY---------- � d f &.------------------ F
� al _.---•.......................................................•.....
has been installed in accordance with°Elie provisions of TI�: 5 o/ �/�tate Sanitary Code as a 'b - in the
application for Disposal Works Construction Permit No----4_t.. 7"-._--__. dati ...................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE T AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................... :P t _�...------•--•--•--•------- Inspector---------.....--------�-.....-------------------•--...-----••---......--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE TH
f �1 .
- u�.No. ...
................. . FEE.... r
i osal �ur�kg Toa,, iuit rroti
Permission is herebyrSte ------..._/..!_!.1'!_ L f!__
g
to Construct_ ) or Repai n Individual ewage ps S tem�
/ �� -
Street
as shown on the application for Disposal Works Construction Permit No.._ /:7 � � _ __� ......
8 -----:ij Dated----=-- - ------ -
............................. =<- D-•
f Board of Health
DATE............................... .....................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS