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I THE COMMONWEALTH OF MASSACHUSETTS
BOARDZ
F HE.ALT
.... .....OF... .... .' /. ......... ..............-----
Appltrattott -for Uhipatitt1 Warkii Cnowitrurttott Punift
Application is hereby made for a Permit to Construct ( ) or Repair ( 1111'an Individual Sewage Disposal
System
�
= - . ................--•'--..- c
..'•-••---•----•---------.-•---------------
ca n-A ss
-n------ � Lot No
�y Ow r Address
............. ......... .. ......................-............................---.....--------------------------
Installer Address
d Type of Building Size Lot_-------------------------Sq. feet
U Dwelling ZN . of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ._._-------------_------- No. of persons.-..--_-----.------------. Showers ( ) — Cafeteria ( )
dOther 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 'Pest Pit.................... Depth to ground water................__..__-.
rX, Test Pit No. 2............--.minutes per inch Depth of Test Pit......--_-.------. Depth to ground water........................
P4 ----------------------------------------------------------------------------------•---------........................................................
0 Description of Soil..-Ilk _
U -----------------•---------•------------•-------- - - - - - - -
--------•----•------------- •----- ----------------------- ------------------------ --------------•------- --- ------ -----
W
x /-------------------------
N ture of P.e str or Alt ation saver when a i le._... . . . . f�1 CJO------_ ... �1 __...._...-
- `�' P ----- ---- -------
V � P• ,.
M&... ------. �✓t,�� tee-
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 een issued y the�oar of health.
Signe
I ......... -------
Date
Application Approved B
Date
Application Disapproved for the following reasons----------- ------------------------------------------------------------------------------------- ..........
...•••-•--•---'-•----'------•---•---------••-----•--••-------•••••-------•-•---'-'--•--•---••••--•-•-------------------•-•--------•--•--'•'---••••-•------••••----------------------•-----------•-•-----
Date
PermitNo......................................................... Issued------------------ ---------•-------"--•-----------•-•- 3
Date
FE$... .....................
7
THE COMMONWEALTH OF MASSACHUSETTS
{ BOARD OF HEAL
-T
,.
......
slirtttina� -for lia uiittl Works Tonstrurtion Vamil
Application is hereby made.for a Permit to Construct ( ) or Repair (.elan Individual Sewage Disposal
syst�
"Oof----------- ca n -- ss ♦ ...................•••••.......or.Lot No.
Own<r _ Address
pInstaller Address
Type of,Buildin�gI :.f '.#�f x,r Size Lot............................Sq. feet
�-, Dwellifie. 6 ofMrooms................................ .........Expansion Attic ( ) Garbage Grinder'. ( )
aOther Type of Building F` , ......... No. of persons____________________________ Showers ( ) — Cafeteria
d f'Ot11er -f R uresI.
--
W 'Design Flow.::.........................................gallons per person per day. Total daily flow-------_....................................gallons.
W Septic 'Tank—Liquid capacity-------.----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 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-"Pest Pit.....................Depth to ground water---------------------_-
f-14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........---.............
x -------- -------- --------- ---- .
0 Description of Soil_. -----------------------------------------------•---::--------------------------------------
x
V ------------------------------ =
W ----- - - ---------- -- ------------------------:---------------- ------------------ 1
V N ture of Repair or Al`tj"ation swer when ap i le..._j"'"-, .. "'"' ---p aD........ .....: 111t ---------- .
- --- - /. -• r►"err+--. .4/Lr4e!-------------------•------•-- •---- ---:_--- ---------•-•--------- ------
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 een tssued`' y th oar of health.
Sne
Date
Application Approved BY---.......{,�•---• r- .............• �j 7
- ..............................
Date
r Application Disapproved for the f ollozving reasons:--•-----•-----------------------•-------...--------------...----------------------------....-••--•--------•_....
Date
,. Permit No.- ...- ------•--------•-......................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF .H.EALT
,... .... .............OF.... ..44?A_*_4........ . ...:......:........................
101rrtif irate of Tompliaure
HIS IS 0 C R'l That the ndividuaj#Se ge Dis 1 Sy tem constructed ( ) or-Repaired (jW
by.. � j'. 014400
nstaller
ate!' ' ''
has been installed in accordance with the provisions of :Article XI of he State Sanitary Cod a desc d -in the
application for Disposal Works Construction Permit No............ ...a_ dated---...-- ,, --'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEDAS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------••--...-----------------••-------------------------== Inspector-------------------=----------------------------------••......--•••---------•-..----
T,HE COMMONWEALTH OF MASSACHUSETTS
BOARD` OF HEALTH
No...... f FEE. ....................
�i��1� ttl g k,� � �trixrtt>aE ,�r_rnmit .
Permission is herebyranted_ ....... . ... ........ .......� :- t ---- .------.".Z�" „��r...-----
g
to Cons c Re it ( Xn ivid S e Dts al Systat No.. � -- ...................................... -- ------M,� '--`......................... .......••---•-••------
as shown on the application for Disposal Works Construction-Per No ............. Dated....\l -��........��_______
DATE........ �. =---? `�. = --.-------= oa t Health
Board. o
'
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS