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THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
............0 F.. . ...C�.:- j..:---------------------_..---................_----
Appliration for Diipuiial Works Tonstrurtion Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
..... .f� . .. �-u..�..� .... ---
LocayInAddres or Lot No.
ror_ ?... ......er Address
nstaller Address
Type of Building , Size Lot___________________________S q. feet
U
Dwelling—No. of Bedrooms _v......................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other 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 ( )
Percolation Test Results Performed by.......................................................................... Date---- ..................................
Test 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........................................................................................................................................................................
x
U ...•------•--•••-•••---•--•-•--••••---•••--•••--------------------••-••----------------------------••-----•-•---•-•-•.------------•-•---•-----------•-•-•---------------------------•---••-•--•••-••-•--
W -----------•--_-•-----------•---------•---•------------••-•••-----------•---••-•--•-......••--•-•------•--------- ----- ------------------ ••-
UNature Qf Repairs or Alterations— when a plicable._.. ' /--' l �11 �..._..
•• •-• ---•------ •.. --•-••-•----.•. -------•-------••----•-•---------------••--------•-•---•--•-•----••---••-----•-------•••-•. ..................
greement:
The.,undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provi§ions of iITL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has e issued V the boa d of heal .
Date
Application Approved By...... .......- ---- .
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------••------.........--
-•---•------------------••-•-------------••---------------------•••------••------•-•---••-••-•--...........-----------....-----------...------......= --------------------------------------•------
to
PermitNo......................................................... Issued_------(y------`-� 7 .......--..
Date
C7,;�)
•' No............ lc.... Fxs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
�� JPF` HEALTH
.`'f-'�s}'2.-�........OF...K.:.5..C'(✓✓'Z-�y-� ---•..........................
ApplirFation for Uisvoa al Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
Syst a)• _
....-• ................................•-.... h ... ..... .<... --•....
Locatibn�'Addres or Lot No.
-e------� ..... ........
r / er Address
...` ....... f --.. Address._..._.._...
?;alIer
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms� `'..................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type T e of Building ............... No. of ersons.._.._.._.........._._______ Showers — Cafeteria
f-4 yP g ------------- P ( ) ( )
a Other 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 ( )
'-� Percolation Test Results Performed by.......................................................................... Date........................................
Test 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.......................
Pa' ---------------------------------------------
--••-•--------------------
•------------
•--------------
-...----------------------•....
••......
•--------------••-
ODescription of Soil..................................................................................................................-----........-----------•-•••••......---••------••...
V ....-•••...••-•---••••••---•--••-•-•--••.................•-••-......•-------....•--••-••------•-••......--•-•---•-- -••---•------•-•----•--•---•••---•••-------•-•••-••--•......---•-•--•-•---------••-
---•---------------------------------------------------------------------------------••-•-•----•......--•--•• . .
U Nat r�ee airs or Alterations— when a pp livable__. __._.. .`�'' _ -"....... ........ t �r __.�•-.-•-)r .................. .... ---`..........................
greein t
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITALE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bye t�,issued by the boa d of health.
,r,/ Jf Date
Application Approved By--f -'=- ------•--- -- ... ----------------------------------------
Date
Application Disapproved for the following reasons:................................................................................................................
...............................................................................................-----------•-•-•----•-•--••------••----•---•-------•---•---------•-•-•--•----•••-•....................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
� - BOARD OF HEALTH
,/ G -C.I....,,,1 0F� -"Z.`� '7..J.............................................
i
�rrtifiratr of TontpfiFatta
IS O � RTIF 7, at the dividual Sewage e Disposal osal System constructed or Repaired _
C��. r� g P .. ( ) P ( )
by-----� .�.... .-
Installer
'' .............................................................
at .l... ..............................cam_ .........------ ''-•---'�.,�
has been installed in accordance with the provisions of T6V..
5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No___ . dated_...l�_.'_.
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
�- " ' BOARD OF HEALTH
ry
- ' F -'l<' '?..1.................................................
No................
d FEE..................
ioor Too; trion rranit
Permission is herebyrant d. '�... 274�1
....-----
g �-
to Constr t ( ) or ) an ndividual Sep rage all System
at No ! . :��" ,,
r.....__:.......---••------•-•-•--•--••-•--•-•-•---•......•................
Street- � �
as shown on the application for Disposal Works Construction P it N _:. _____._ Dated.._eA___._.". ��_._.__......
y
j/Jj/(� / --/- J
•__,�_�_.:_lt. ..__ /•---h...........................
Board of Health
DATE.--- w---• -••------ .....................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS