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IN .',T
No.. ....: ..�..... Fps..v.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEALTH
\ d 1..............OF......--. .......................-..--•---
a .
ApplirFatilan for Disposal Works C�onstr�trtiun rrntit
Application is hereby made for a Per to Cons �uct ( ) or Repair (�) an Individual Sewage Disposal
System at• `� L.:Y - ................
.......... .. .-- --
Loc io A ress or Lot No.
I .......... f -- --- •- ........................... ....................•-•-••-•••-••-•-._..._....__._...----•-----•-----..._..•-----..............--
n r �_��/ Address
W •�--`--________ ___________ _______________________ _______ -------
___........
_-_----------____-__
Installer Address
d Type of Buildiljg/' Size Lot............................Sq. feet.
Dwelling '. No. of Bedrooms.........................................___Expansion Attic ( ) Garbage Grinder
'L Other—Type e of Building No. of ersons____________________________ Showers — Cafeteria
a YP g P ( ) ( )�
Q' Other fixtures ________________ ___________
d .._....................••--••••-•••----•-•--•••••......••. •---•---•--••-••-•-•-•••--•-................................
ga
W P Design q P ...F.�. Per Lengthperson Per day. Total daily flow.........................••---• --_gallons.
WSeptic Tank' Liquid ca acit ..gallons ss ..........::.. Width.- _._.__. Diameter.-.-_.__._.___._ Depth..:_____.___....
xDisposal Trench—N _ _____________________Width_ __._.__..._...Total Length.._-____:._ Total leaching area_--____..___-__..: sq. ft. .
No /Ox
Diameter._... De th below inlet....... .......... Total leaching area.. _
� Seepage ,Pit o------ --------- -- -------- P g �.�..-sq. ft.
Zy Other Distribution ( ) Dosing tank ( )
F" Percolation Test Results Performed by-------------------------------------------------------------------------- Date.........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------------------
•---------------------------
-•_•_...._-•--- •••......-...
0 Description of Soil..........................•-•--•-=------......----•--•----........._---••--••-••--•-----•-••-•-•• • .••-•••.........................................................
V _,,
W ---------------------------•-------..---------------------------••----•`......-••-••.......---•-.----• ------------ ---------- .-•••••-• .... ............. -------
Nature Nature of e it or Alterations—Answer when applicable. f' ----------------- --•-•-
Agreem _
The undersigned agrees to install. the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT :;
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health. .
Signed
Datt
Application Approved BY•...... - -- --- `�� J�y7
Date
Application Disapproved for the following reasons----------------•-•----•----•--------------------------...----------------•--•---...-••----•••---------•--•_-_.
------•.........................•----••-----•----•----------------------•-•---•.._..._..--•---------••--••-••-•----••••-•------•--------•--•-•••-•----------•-•---•-•-•••---••••--------•-•--•••••••---
Date
V-------------------
Permit No.......................................................... Issued_.--•••• `-
Date,
t 7�
No..- -- • ._._....... low
Fss...................... . ..
`"q= THE COMMONWEALTH OF MASSACHUSETTS f
BOARD IPF HEALTH
OF.
App iration for Disposal Works Tonstrurtiun Prrutit
Application is hereby made for a Permit to Cons ruct ( ) or Repair (/") an Individual Sewage Disposal
System at
Lo io -A' ress or Lot No. $
.................................•----...---........_............................f
Address
.. .. •..'............. ................................................. ..............................................
Installer Address
UType of Build' Size Lot............................Sq. feet
Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type of Building No. of ersons____________________________ Showers
a YP . g ---------------------------- P ( ) — Cafeteria ( )
dOther fixtures -------------------------------------------------- . --- ---------•----------...--•----•---•----•--•----......-------•--••......•--••__--•-
W Design Flow____________________________ ___ ____gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank--Liquid capacit �` .gallons Length................ Width................ Diameter---_............ Depth................
x Disposal Trench N ,___..:.. Width_ .Total Length.......... Total leaching area............ sq. ft.
Seepage.Pit No. ___ .._._.._. Diameter.____ ._ Depth below inlet....... r___._ Total leaching area..02.4t- sq. ft.
Z Other Distribution ox ( ) Dosing tank ( )
6.4 Percolation Test Results Performed bY........................................................................... Date........................................
o
Test. Pit No. I________________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_....._.................
9 •-•-•------------------------- --•-••--•---------......_.._.__........_...._..--------••••-•----------•---.._.......-•--•••••...-----•-----..._.......
0 Description of Soil................................................................-......-•-----••------------------------------------•-------....._._.__......-----------•......---_-----
x
W ��----
U Nature of e Ir or Alterations—Answer when applicable.
. . .-----. _.
..-•----. --------- ----- -------- -------------------�.._.._...------........_...----
Agreem
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iiT L
p S of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signe ............................................................. ................................
Da
Application Approved BY ;. ...........
Date
Application Disapproved for the following reasons:_..:............................••-------------------------...-------_______.._.____..______:_________...--...„
..................................•------..._._....---------•--•---------•-•--•••------...._..--•--•-------•--------------------:...-......--------------------------------..........................
r .ram Date
Permit No...........................................L; Issued._._..._...
Date
THE'COMMONWEALTH OF MASSACHUSETTS
-, BOARD O ^3' EALTH .
.......,... .........OF.... }..: .._ `�' ,,:'......................... .Jr .....
T' IS TO CERTI T t dividua 'Sew 'e 1 :S stem constructed ( or Repaired ( )
by ............. -_..._
st
r
application for Dis.os
has been instal i accordance:with the provisions of TITLE j of The State Sanitary Code as described in the
pp Disposal Works Construction Permit �To---.__.__�1��.__ .___ '_. dated-...��.""f,.,,�"�. �.__, _` _______.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A_S A GUARANTEE TB A; T THE
SYSTEIVI •WILL FUNCTION SATISFACTORY.
DATE......:...--•-•...................:. Inspector.....
- �.
THE COMMONWEALTH OF MASSACHUSETTS
-BOARD ' HEALTW
. ....... ......... ....OF... tom''_-.'"" Z......................................... FEE .
...........• b ..
t us Works n #r n Vamit
Permission is hereby granted__ y :..... __ _ _____ ___
.....
to Co istru , ( ) or Re al
) n Individual Sewa Dis osal ystem
q
Street }
as shown on the app ication for Disposal Works Construction Permi ~. _-_______ .. �_AD _
w
.. 'B
oard of Health
DATE
FORM- 1255; -HOBBS & WARREN, INC., PUBLISHERS ,,
<ION
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