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THE COMMONWEALTH OF MASSACHUSETTS
T - 4BOARD F H EAL
/�
-----..........OF........ . .
` - ----------------
Appliration for Dispaiial Warks Tunstrn.rtion Vrrnfn
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
...........................ct'---- ---------(!In .�,.>�c-------- ...................................y4i---.....'f Z-----.`-----------
n / Locati n-Arad-sIs-`_ y�o-r °t No.
.. ._.0 v` ...........
....3 .�---8��!��i�
Ow er ress
cu^' ' I �� ------------------------ -- ......
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling L-No. of Bedrooms.......... ............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers Cafeteria ( )
a' Other fixtures ......................................................
W Design Flow........................� .........gallons per person per day. Total daily flow----------- ? _....T..gallons.
WSeptic Tank—Liquid capacity/_'-wv_-gallons Length-------------- Width--------.-..---- Diameter---------------- Depth_-_-______---_-.
x Disposal Trench—No.____________________ Width.................... Total Length....................:Total leaching area....................sq. ft.
3 Seepage Pit No------ ' ... Diameter____________________ Depth below inlet........... '_. Total le ping area..................sq. ft.
z Other Distribution box Dosing
ox ( ) Dosing tank ( ) 1/7 a - � "�'`
Percolation Test Results Performed by.......................................................................... Date--------------------------------
aTest Pit No. I................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__________________________________ b _-
-ay,: !
_ =
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 agrees not to place the system in
operation until a Certificate of Compliance has bee i ued by the d of h lth.
Signed -- = -'
�j Date
Application Approved By '--- ; . --------{....-= -- - --= ---- --------- -------------
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued------------------.....................................
Date
No.--- . .._ ... Fim..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct ( , ) nor Repair ( ) an Individual Sewage Disposal
System at:
................�-�r--•�-----•------------•-•-----•--•--...........----•-... ---...............................................................
Lo�ationnt� -ress or Lot'No.
Owner Address
W
Installer Address
UType of Building - Size Lot----------------------------Sq. feet
Dwelling� 0. of Bedrooms------------------- ......................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ..........................................................................................................
Design Flow....................... ....._._gallons per person per day. Total daily flow.......... . m "° ......-r-.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 ( )
Percolation Test Results Performed by--------------------------------------------------------------------------- Date----------------- ----------------------
a
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.----...______-_•-------
---•--•-----------••--••----....----•--•---•-----------------------•----••......--------•--
ODescription of Soil...................................................................................................................................................................
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
---•----•--------------------•-•--------------------•-•---------------.--•-•---•--•-•-•------------•---------•-------------------••------------•--------•-•---------------------•----------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Co —The undersig ed further agrees not to place the system in
operation until a Certificate of Compliance has b- tssu by ie bo r of healt .
.I Sign 1 -v
r� -Date
Application Approved By..-.. ....` �V
./.
at
Application Disapproved for the followiny reasons:-------•---•-•-•------------------,----•--••--••------•---•----••--------•-•-•------•---...........................---•-.....
-••--•-•-----•-••••••----•--•----•-••----••-••-••-•------•--•--------•-••--••----•-•---•---•---••-•---•-----••--•----••--••--•••-----------------------••-----------•---•-----------•------ -•-••-----•-
Date
PermitNo......................................................... Issued............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF............ ` •" ..
C prtif irate v f�LIntli Lure
, dividual Sewa e Dis osal S-stem constructed or,Repaired
- -M1 g P �' ( ( )
by IS I Y• T ... . .. In ---------- -----------p------•-----
-------------
Inst�r A �i .
R "64y g
at ----- y ----•- y -- -"�'ff------•----_...�`4�„'_-h_ r s"fig°4
has been installed in accordance with the provisions of Article XI of he State Sanitary Code as described in the
application for Disposal Works Construction Permit No-------------- 4___....•----------- dated....._...67 _: __- .......
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 HEALTH
,� ...• f _
FEE_
Permission is hereby granted- :.-
-•- - _— ...----
--
to *TConstruct orr epair ( ) apn�Ind'widual Sewage Dispo p'S m
at 1VTO._� ,n " ... xwl......_ S[ �` "'S` r ^rl+yw r €- ---Street 5�� �'� +r +t................
as shown on the application for'Disposal Works Construction P mit No :_ Datecl--- c _ ,
—25 •----
---�-- ••`. Yyas�!ir' _ = 5` _ ',,g - a•....•---_••__-•-'----•--.
'r. Boarof earth t'
DATE................................................................................
FORM 1255- HOBBS & WARREN, INC.. PUBLISHERS 4
' 3.