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S M E A D
KEEPING YOU ORGANIZED
No. 12134
2-153LGN
RMKWM MIN.RECYCLED
INMATNE CONTENTZ%
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MADE W USA
GET ORGANIZED AT SMEAD.COM
No.- ...... FEIC(L...............
THE COMMONWEALTH OF MASSACHUSETTS
EOARD F HEALTH
......................
to t t-...�'rrr-I i 4t
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: G
----...._••-••-.... .�.....................�_ ............................................... _.__ ...... .........................................
L�occaatiiioon,�-Address _ or Lot No.
Owner Address
a ..........0 :55� .1— �....................'--•----
Installer Address
Size Lot----------------
Type of Build... C, Sq. feet
U Dwelling 4 No. of Bedrooms................. ..... . . .. -Expansion Attic ( Garbage Grinder (X)
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtur. s
W Design Flow..................... . .... .....�,.,..__,,_.'1__gallons per person per day. Total daily flow.............._ _.__.__................gallons. /
WSeptic Tank•-Liquid capacity�.u-v_gallons ` Length...._----------- Width................ Diameter_--.--.._-._... Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. /
Seepage Pit No........D-�______ iameter-------------------- Depth below inlet............... . Total le ling are ----- --------_sq. it.
Z Other Distribution box (� Dosing tank ( ) � �44
� 2s1,
'-' Percolation Test Results Performed b
W y..----- -----•----------•-•--------------------------------------•--•=--- Date........_....----- ----------_--------
Test Pit No. 1................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_.-.---__-___--_-----.
---------------------------•- -- ---- •---•----•-•----•-••----------------•----•----•---•-----
O Description of Soil-----'--------------------------------
U r � '� - ------------------------------
--------------------------------------- ------------------------------- ---•--------•---•--------••-•••-•---.......------------.
W -•------------------------------------ ---------•--------------------------••••------•------•---•---------------------------•-----•---------------------------------------------•-----------•_----••----
UNature of Repairs or Alterations—Answer, when applicable-----------------------------------------------------------------------------------------------.
Agreement:
.•r
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitar, Code— Th nders' ed further agrees not to place the system in
operation until a Certificate of Compliance has en issued by e and o healt
Sign - --- -------------•-- •---•-'--••- .........•-----•--
Dat
Application Approved BY . . ---- •
ate
Application Disapproved for the following reaso s-------------------- -- --------------------------------...._............--------------------------••-•-
---•-•--•---•-----•------•----------------•--------------------------•-----•-----•---•-•• .................................................... ---------------------------------------------------------
Date
PermitNo......................................................... Issued.........................................................
Date
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NO.J_.. ........... FEaa ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH..
C - 2 -1
App iration -fur Uiupuottl Works Cnunotrudion Vanift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
LocattR ion-Address or Lot No.
�- tj/y i� t. n - t.`, OtG1N _-7? 'AIt
••--•-••-----••---......•-••--.....-----•-------•----------•----•--------------------------------- ----•--........_....-----••---......--•---......_.._------------•----•......-----_......._---_....
,.� J Owner Address
_____________ ............__.......................................................... _...__._...._...____.__._................__.___......___..._._______.__._.____.__.._.__.
Installer Address
QType of BuildiIL ngs 4t Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............. -----------------------------Expansion Attic (; Garbage Grinder (x)
Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
GI Other fixtures .----°------------------------
W Design Flow..................... 1.� 1 gallons per person per'day. Total daily flow............ _--._.------gallons.
WSeptic Tank / Liquid capacit��:S.770.gallons Length................ Width-.:--..-.------. Diameter---------------- Depth_--__._.--.--.
x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No.___-.--�: ------ Diameter-------------------- Depth below inlet------.___t___�.. Total lea- iiug area--.--- ----------sq. ft.
z Other Distribution box (11__� Dosing tank
'- Percolation Test Results Performed b .. Date------------------- -
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--.--_--__---.-_-__-. --
-•--------------------------r�-j---'- ---- ----------- ----- = -- - ---- -•--------••-------•----•--.----•-.-----•--••-------••---..
D Description of Soil------------------- :i'.__,° C-a - -'rr--Grp -
V ---------------------------------------------------- ------ - -------------------------------------------------------------------------------------------...........
------------------------- --------------- --------------------------------------------------------------------------------------------------------------------------------------------------------
UNature of P%epairs 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,�mder5jgned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board�91 health
ih 't61 ,1.t..-,07 �rGa-;_x`�--'�=----------------
J Signed.=----- .--I---!--------•-----a=--._. _...._ ................................
Date
-
Date
Application Approved By..--t,r-'• n_., '__ ..... U- -:.; `
1 Date
Application Disapproved for the following reasd�is:.............................................-.........................._---------.----------------------------
-------•----•----------••--------------------•-----•-----------------------------------------------------••----•-------------------------------•--••-----•-••---------------•---------------------------
Date
PermitNo......................................................... _ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /I
t
r T rrtif irate of Tontpltanrae
THIS IS TO CERTIFY,lThat the Individual Sewage Disposal System constructed ( ) or Repaired ( )
_
by =, / - r ,71
e , =
.... A 4� Installe --"L-t
s'
at............. a Wit.- ----------
has been installed in accordance with the provisions of Article XI of jhe State Sanitary Code asdescribed in the
application for Disposal Works Construction Permit No._----._-_ Jr___ ........... dated....t' _rr _ ._ ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THATTHE
SYSTEM WILL FUNCTIO SATIS CTORY. - _% -w ��'/`� � � - .�? z
DATE --------- r ll .. .............. Inspector �C' 6
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........?....�....'.�,�:..I......OF......��,.-1....�..."�"' ...�f "'�--'.`R..... j
FEE-
%spoptt1 ork_q 0411fitrurtion Prrutit
Permission is hereby granted_..-('' `- ": ....
to Construe( pair .............................................................
(,f�)✓a>�ndivtdual Sewage,Disposal Syste
at
Street
as shown on the application for Disposal Works Construction Per it No.Z_� ....._. Dated- ._-_f ____.._.�'--
Board of Health
f _ /., f
DATE-------------------------------------------------------------------------------�_ !.2 S'CJ f _ ,✓ "' -(,,. ,/�'. 1
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS