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No.._.1...7 ..... F�$. .. :...............
THE COMMONWEALTH OF MASSACHUSETTS
�r17 BOARD OF HEALTH
OF..................................... ..........................
Appliration for DiiiVo at Works Cnowitrurti n Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
g � f
Locati Ad es ts
� or Lot No.
Own dress
, 6*"
----•--•-•-... .
Installer Address
Q Type of Building Size Lot________________•.__.--____-Sq. feet
U Dwelling—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--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width-------- ------- Diameter..........------ Depth..---------------
i ,.g- i
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--------------------------------------..
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...-_-_-_------.--_-.
I:lq Test Pit No. 2................minutes per inch Depth of Test Pit......._............ Depth to ground water__.-.--_.___--.--_-----.
••. -----• •--
o �`.
Descriptionof Soil -------- ------------------------------------------------------------------------- -----------------------
U --------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------
------------------ --------------------- ---------------------------------------------------------------------- -�----/�
V Nature of Repairs or Alterations—Answer when applicable. /_. -•- L'__ `
-------------- ?�:._..._. _�� :-_..... ----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State San it'
de— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ee is ed IN the b and •f alth.
g ........
Date
Application Approved By------ ....� ?
Dale
Application Disapproved for the following reasons________________________________________________________________________•___._........._........__......_.......
------------------------------------•----•-•-•---.....-----------------••--------•-..._•--•-•----•---•---•-----------•--••-•--------------------••-•-----••----•-------------------•••-•--••-------•--•-
Date
ry
Permit No....--•--•-•-•--------"----•-••---'•-'-----------'-'... Issued•--- . .._ ..
ate
1�
No.-- # Fss....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_._._.. _. _.. .............OF...............................
..........................................................
Xplifirati n -for M_qpuiitt1 Workii Tomitriartton Vantit
,� 1
Application is hereby made for?`d^Pemit' too C`�on'struct°( ) or Repair ( ) an Individual Sewage Disposal
System at: I /I .+
r
................................ ----- -
(� L,?C t1iJ�? Addres f� My or Lot No.
..........................................................
'� ;,' Owner' `� �-a- - �� "'`�`- A/JAddress .' � r�.�,�•�r,,�i''�,sl�rr
................ - ..... ............. ._.c;xu......... .. ....vv!!`....f^�
Installer Address
Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedroom's_________________________________ _________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of ......_. No' of'Persons............................ Showers Cafeteria d Other fixtures ------ -------------- --------------------------------------------------------------------------••-----------------------------•-------•------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons ALength:............... Width.................Diameter_:-----_------_ Depth_--.--_.-----
x Disposal Trench—No_____________________ Width.-_f..........__._..-Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet-------------------- Total leaching area-------------------sq. it.
Z Other Distribution box fiDosiitng4!aao ( ')"
aPercolation Test Results Performed^by- ------------------- ------------------------------------------------- Date........................................
Test Pit No. 1................mi�nutes per inch- Depth,.f! Test Pit.................... Depth to ground water-..-_-..--__.--..-----
Lt, Test Pit No. 2................na nutes�per inch D;ep�th f�ffest Pit.................... Depth to ground water-_._---..__.-_-.--__----
" '
O
x Descrtptlo� f Soil__:!_ 'j �
.......................... •--•-•-•------•---------------•----••-••-----••-----•................ .._....----•-•--••---
U --•-----------•-- -------•---------------------------•"---------•-----------------•-•-•----------•--•-•--------_-------•--•-----------•-•----••--•----------•------------•-------------•---.----------
W V,.
---a__-__-__- f•£ _ -__ .___ ______ ______________________________________________________________ __________ ---..__-_.-__ __-__---.___. .
UNatur�e��of Reirs or Alterations—Answer-when applicable.-.__f -- '�
----•••---- --•-••---••--•-•-••--------------------------------------------------•------------------------ --• . ........ ---------------------------------------------
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 rbeenlissued by the board of health.
.. .......
- f j at
e
Application Approved BY-.- �- . ...... ......-
..
Date
Application Disapproved for the following reasons------------------ ------' ------------------------. .....................................................
----------------------------------------------------------------------------------------------------•----'----------------------------------------------------------------.....------•--••---••-•-••••-•-
Date
PermitNo........................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF.ej HEALTH f
" '" .........O F............ s!tr...�2. -�
Tutifirate of Tomp tatty -
TAPS IS TO CF/RTIhY`rThat t I dividual�Sewage Disposal System constructed ( ) or Repaired ( )
tea.4..•. .
has been installed in accordance ith the provisions o Article XI.of The State Sanitary Code as deex`ribed in the
application for Disposal Works Construction Permit No---- ------
.........
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 OF7 HEALTH
�
�' ............+. ...........'..............OF......�z .:.'� r' i�...' :........................-------•-.•
f No.-• , � FEE :............
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rti $t; rrnft
P rmission is.hereby granted---= ---- -----+✓-." ._ _ _ _ Ze_ �` .-el--I-j------
-
t Co truct r' Repair ( )p an�I dzvtdua.LSe� ge Disposal;System -A-------
r N« f N
aaN _, __._ A _ r r, ----- `t _ _' ` ?....._... �! _ 1.._. i' , ---- `------•--•
f ,treet -g
as own on the application for Disposal Works Const/'uction Permmi o.-_._.. � _�,D f d__ _, "'F _...../.___..�.
41. Board of Health
DATE -= , °z . `/I`--------------------------------------
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS