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THE COMMONWEALTH.OF MASSACHUSETTS
0
BOARD OF HEALTH
6�A/-----------------
OF.... .. ....11..... ...................................
N.Vpfiration for Dispasal Works Tongtrurfitin ramit
Application is hereby made for a Permit to Construct or Repair (L-<an Individual Sewage Disposal
System at:
.............................. .................................................................................or.
Location-Address •or Lot No.
to
....................... . ............
.......... ...... .... ......
(17;i�er0\0 4 . , Address
V .5
.......................... .....................m.............................. ..........a---I....... ..................
Installer Address
Type of Building Size Lot............
:.................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
Otherfixtures .............................................................................................................
Design Flow....._.. �........................gallons per person per day. Total daily flow.........
Septic Tank—Liquid*capacityNO gallons Length---Y........ Width.....�P........ Diameter........*........ Depth...............
Disposal Trench—No. ...G............ Width...�3........... Total Length....Q.a.......Total leachingl:area....4�_&zP-----sq. f t.
Seepage Pit No..................... Diameter..........._.._..__. Depth below inlet...........:{._._.... Total leaching area..................sq. f t.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by------------ ............................................................. Date........................................
1.4
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.___._.__..._._......._.
............................................................................................................................................................
0 Description of Soil...................................................................................................................................................................
....................................................................
-----------*-------------------------------*-------------------------
----------------------------- -------------------------------------------*------------------- --------------------------
- ----------------------------------------------------------------------------------------------*--------- -------
U Nature of Repairs or Alterations—Answer when applicable...__ ....... ........
..........1311.-Ir.. ......................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL I'i 1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of CompliancQ,::���iued�by ke boar
Signed.-----,,,p------_-------
1,0;;.2------------------- .............................. ...............................
Date
boar.......... .......................
ApplicationApproved By................................................................................................... .........................................
Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
Permit ...................... Issued.......................................................
Date
`Z
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..4. OF... . ................................
Appliration for lliipn,i al Works Tonotrnrtinn rprmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
--------
Lo:a�{'on-Address or Lot No.
Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...._`7...................................Expansion Attic ( ) Garbage Grinder ( )
`04 4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
W Other fixtures -------------------------------•--•----••-••--
W Design Flow.........` _S. .................. ..gallons per person per day. Total daily flow...........4�.Q...............gallons.
-
W Septic Tank—Liquid capacit���?gallons Length.......... Width---(P........ Diameter................ Depth_....__
x Disposal Trench—No._._&.._._...._. Width--_....._.... Total Length....L rc-:)...... Total leaching area_ �u Z ..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........................
LZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 --------•----------------------------•---------------------•----•---•----•-•--------...............•.........................................................
0 Description of Soil...........................................................................................................................................--------------------------
U - .-..--•------------------------------------•--------.--•------------------•------------••---•---------•-•---------------------------------------•-------------------------------------------------------
W
-----------
U Nature of Repairs or Alterations—Answer when applicable______•_-15_9: _..T_. ....... !. _S:.... L?.�.C......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Complianc -b} the b
"Signed ------------------- -•-----------_.... ---.. -• ................................0\ S�
•--
Date
ApplicationApproved By..................................................................................................
Date
Application Disapproved for the following reasons-----------------------------------------•------------------------------------...-----••---••......-------•..._..
1,
..............................................................................................................-------•--•------------•------........................••.......-----'• ......-•----.
Date
Permit No..&a..... . .......................... Issued--•------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
•••��.. N................OF......1.=%. ..o'.. .....! .. ..............................
�rr�if irtt#r laf �nrnt�rlianr.�
THIS IS TO CERTIF , That the In ividual Sewage Disposal System constructed ( ) or Repaired ( )
- ••----•--------------------------•-----...----....._..........---•••-•-••••--
Installer
at...... ...D..It ........... ..........•---� �..�-;� �� � �° . ............... -----------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit Ncke.. f_��_..2;;,"..•... dated..-./�_ ...�_1.���3'..�:........
THE ISSUANCE OF THIS CERTIFICATE SHALL°NOT BE CONSTRUE® AS A GU RANTEE THAT THE
SYSTEM WILL FU14CTION SATISFACTORY.
DATE....................... ......... Inspector......r� ---•------`-`j•-�-�----------...-------•-•--•---------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f / if
No.... . .....J f/Q t.. _
aI nrk�R....Permission is hereby granted--••---- &a<�'`------•• . ------ ----•--•----•----••-------------------------------------•--•--•---•-•---
to Construct ( ) or Repair (to<an Indiv}dual �ewage Disposal Syst
at No...
c «� - .
Street
as shown on the application for Disposal Works Construction Permit No ' b o7 D . "....
Board of Health
DATE... Z"BS
••-•--•--•--........_FORM 1255 & WARREN. INC., PUBLISHERS
UPPER CAPE
ENGINEERING COMPANY
7 FERN AVE.
E. SANDWICH, MA 02537
617-888.2027
SPECIALIZING IN:
SITE PLANS
SEWAGE DESIGN
SUBDIVISIONS
HOME INSPECTION
PERCOLATION &SOIL TESTS
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