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THE COMMONWEALTH OF
Ass o*ussrre
BOARD OF HEA T
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Application is hereby made for Construct or Repair ( ) an IndividualSewage Disposal
Address
Installer Address
Other fixtures
----- ................... ---------------------------- ---------------------------------------- --.- ---------------------------------------_
Design Flow------------------------...................gallons per person per day. Total daily flow--_---_-.-_-- ---------gallons. _
Septic Tank—Liquid capacity----'-gallons Lcogt6-__-_' VVihh-----. Diamcter-----' Depth------
Dis000a Trench--Nv...................... Width.................... Total Length-------------------- Total leaching area--------------------sq. 6.
Seepage Pit Nu-_--_-- Diameter.......... --------- Depth below inlcL..--'--__ Total leaching area... ----------sq. b�
�o Other Distribution box ( ) Dosing tank ( )
~+ Percolation Test Results Performed bv....... ------------------------------------------------------------------ Duto--.--.---------
Tcs fit No. l................minutes per inch l}cnt6 of Test Pit-------------------- Depth to ground water----.----
Tee Pit No per inch Doo16 of Test Pit.----_--. Depth to ground water----------------------
.-_-_-----------'---_ ............................................................
...............
0 Description of Soil-..---_-.--.__'_''_--'__---''--___-.----.--_____'--------___'_--
-_--_-_--__---_-------_--__--------_--_.-'_----'_-._--__-_--------_---_-- �
The ��-``�'� agrecs to install the oforcdcucribcd Individual Sewage Disposal in accordance withthe provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system |
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in
operation until a Certificate /f Lomyuzuco has
W
� gned
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.M
Application Approved By..
' ° ---Application `
Disapproved for the following reasons:----------------------------------
---
,----------------------------------------------------------------------
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| ---_'--------'----------'---'-'--..---'''-------------''----'----------'���-------
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' Permit Issued........................................................
-_'-_-_----__'__.___'____-
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.......................--'----------------------------------------------------------'---'--'-''-----'----''-'-'
No. ,�b 4''....... Flzs....... 1-....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LTH
......../0"e ---OF._
--
Applirtttiutt -fur igVo,ittl Works Tottutrurtion Ppruld
Application is hereby made fora Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systerri)at:
r '
.....
j i ocation-�Addr ss, �� �.. / or Lot No
C* lr 9a4,tr i or t x3.a�r
Owner Address
Installer Address
UType of Building Size Lot............ :.............Sq. feet
., Dwelling4 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.
Septic Tank—Liquid capacity-...........gallons Length................ Width--__.-..-.-_--. Diameter_:_.--..--.-_-__ Depth----------------
xDisposal 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--------.----._-----.---
f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_._---..--.-----__-----
-----------••----------------------------------•-----...---•----------------------------------•-•-••...........................................-----..-----
0 Description of Soil........................................................................................................................................................................
x
U ----------------_-- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W --------------------------------------------------------------------------------------------------------------- -� ------ *-y---------------
U Nature of Repairs or terations-Answer when applicablet�.__.------ /Z":: I1 __........
�;
=e =�°'=----`-------°. .----------±--�C-�------ �T j '' �h et e'�i�� --------
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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 b A n issuexl,by the oard of health.
Si ned f'! YL �'l �P Via'. ' s_t 0
g ....... ...... y___......._..._____.______a
Application Approved BY Yr�P � ''1---f` '�'` WX
ate 7.
�f
Date f
Application Disapproved for the following reasons:...........................................-----•---•--•--------•---•-•-•----•----------------------•-•--.------
-•...................•----•------•-•.....•--------------••-------.....--------•--•••--....--•-••••-----••----------------•............--•......••-----------•---•-------•......_.•---------------••-----
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.+ OF. '' t"
.............f......:.. ^`.......y...... ......... ..'!+.4....J.w... ..l,i�.ai`w..l'.'�,.�.....��.....
...........................
Trrtifirtttr of f�ontplittttrr
T %S IS TO,YCER,T FAY.'That the I/dividual Sewage Disposal System constructed ( ) or Repaired (4o'`
bY- =- bra �.. � '1
j ,�
V
t`
has been installed in 7ordance with the provisions of Article �I' o�The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....._..........................'�....._..__._._. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE �� ---7 y•----•-----....-•---••---••---•---- Inspector..............................................-------------------•-•-------•---•••-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH r�
..............f :..:..:`.`...r OF..._, i ... �..........................................='..' i
e
FEE...-.:.---..............
�i��u�tt1 �►rk,� C�utt�trttrtiutt �rrotit
Permission is hereby granted_ fir .•-- �"'
to Construct ( ) or Repair ( an�Indtvtd o SewagelDisposal System
�t
61
at No.. /d- lE •_• ,liL i s 'f / t r,.!fit° a �.. ._.�' ° E, �-�/a►!.et i/f r
.... $.
Street
as shown on the application for Disposal Works Construction Permit o. %`. ___.--. Dated.....
, ...
.........................................
DATE..........
Board of Health
/7/ ...._..
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS