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THE COMMONWEALTH OF MASSACHUSETTS
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BOARD F AHTH
Apphratiun -fur 43iipuiitti Works Tonstrnrtiun Vrrniit
Applicatio is ereby`made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: � G Z�I G� t-v..
....................... •---•• ------ ---------------••----
Location. ddress or Lot IV .
.......................?--
�� ...........s....a ...'------------------ --i.....i --'----- j e�i f�-..................... ... ....................................
Installer � Address ���
d Type of Building Size Lot.....� t...............Sq. feet
V Dwelling—No. of Bedrooms._____-_-_�-.............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.--_____---_--__-_-_----_- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- - -
w Design Flow............. ... .......................gallons per person per day. Total daily flow..............9_4r.f .-_____-----..__-gallons.
W t�Q�Septic Tank—Liquid capacj7 ___gallons Length ___________ Width.--__-.---_/Dia�mmeter................ Depth----------------
x Disposal Trench—No. ._._ �Cid � ____ T :.�-.. )`t leaching area.._._ _Z_.;sq. ft.
Seepage Pit No--------------------- Diameteal_-____------.--_.- Depth belo inlet.................... Total leach'Ig<tre --------sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) -i`7— /,i—3 - 7J— ;
Percolation Test Results Performed by--'-'--;------•-------....-'•-------....-•-------------•-•--•••----•--••-- Date-------------------------------------...
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water...--------.--_.--._----
f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__.-..-.---._--.____----
w .__._-.-4_____________ ________ _ ___ __ __ _
h , � ................ ............ -----•-r••
O Descrt tion o Soil = --'--�'-o --� 1_Gc2
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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 b issued by the boar f health.
Signed.- ..._.
Date
ApplicationApproved By......................................................................................... ---- -----------------------------------------
Date
Application Disapproved for the following reasons:--•----•----••-------------------•-------------•-------•----•-•-••-•-•-•-•-----------•-••--•---••-•-••....------
...................................•--'•--•--.........---------'•---••....---•---•-•'--•-•---•--•-------.............------------------•--•---------•-------......---......_...--------....-----•--•-----
Date :
PermitNo......................................................... Issued.---. ......--------
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H H
,O- V. ... .......OF... '"/:................................. ........: ..............................
Apli ir4tinn -fur Di,iputittl Works Tomitrurtiun Vantit
Applicatio is ereby made for a Permit to Construct ( or=Repair ( ) an Individual Sewage Disposal
System at ,
-••
Location• ddress or Lo
�......... 3 ___ _
w.n Q� ,�j� w..
a ...................... _.Y..- / 1��"�M .e.'�R -�"'•"" 1�• !! .. ............. -•---------••------------------
Installer Address ..+
Type of Building Size Lot..... ...............Sq. feet
Dwelling—No. of Bedrooms---_ _-S..•...........................Expansion Attic ( ) „- Garbage Grinder ( )
Other—Type of Building -_____ ___________________ No. of persons .Showers Cafeteria
a g p __ ( ) — ( )
Other fix
tl res ----------------------------------- --- -------------------- --
W Design Flow_-_. __--- __,_._ ...........gallons per person per day. Total daily flow-_..'..'..'. ............ .gallon.
W Septic Tank—Liquid capac>,g __gallons Length-: Width ----- Di 'Deter Deptlt
x Disposal Trench—No Tc '1-. - eaching area....3.d- ---..sq. ft.
Seepage Pit No______________ iamet _-_____-_____.-.._ Depth.belo inlet._:.___:__'_=___..... Total leach• Ig ar , ------------------sq. ft.
Z Other Distribution box ( „) Dosing tank
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Percolation Test Results Performed by--_•-- --------•--.-_-. Datiea--------------------------------------
;Test Pit No. 1----------------minutes per inch Depth of "Pest Pit:................... Depth to ground water_--------------
Test Pit No. 2................minutes per.inch Depth of Test Pit.--_-________-____ Depth to ground water -...--_-_--__---_-
f>♦' ...... - -------- -- -- �# ,,�j���
Descri tion Sw1t4 �s 4yD " `Z *�. �� -w1 k f - %'A4�
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.. I 1[� �/l. ' ----••-•.....
U` G6.ro 4k * / __j...- 1 --•--•--•---------
x ----•--------------=---- •---------------- ------•-•-------------------•----•--------_____------------•--•-------------------•---•-•-----------------•------------- •-•------------------
U Nature of Repairs or Alterations—Answer when applicable............ --------------------------------------------------------------------------------
----------------------------------------------------------------------
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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.41ndersigned further agrees not to place the system in
operation until a Certificate of Compliance has bpeMissued by the boar f health.
Signed
Date
Application Approved B • '
Date•
Application Disapproved foralze-following reasons.:.............__.__.___......_.
--•----------------------- ••--------
--------------•--••-----------•--------------------------------------------------
Date
PermitNo......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT
................O F...............................................................:.....................
Trrtifirntr of 0111mplitturr
THIS IS TO CERTIF , Th the Ind-vi al Sewage Disposal System constructed or Repaired ( )
by e ...." ..... . ./•••. •--•-•--•-••--••----- -
-- ---------
Inetalle✓ •--_--
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has been installed in accordance with the provisions of Arm XI of The State Sanitary Code as desc--bed in the
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 F H`EALT
No......................... J. �O
----------------------------• FEE........................
i� u ttl ur � nitrurtiutt Vrrtnit
' y granted. ' -------- ------- .......................................... ----•___-----___-- -•---
Permission is h reb
to Construct.- (, or ".pair ) an In 'v•dual ewage isposal ystem
at No ------ ----------•--- J
as shown on the application for Disposal Works Street `
pp p rks Construction r it ated.....1-'. �._7 -
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•------
_. —` - .,$oar .of, al , ' M
DATE ,
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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