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THE COMMONWEALTH OF MASSACHUSETTS
�vZ BOARD ,OF H E,6LTH „
............ .OF...... -----------------
Q/u1 . pp.1iratilan -for Di- aaiittl aark.i (nvniitrurtivn Vrrmil
Application is hereby made for a Permit to Construct '( ) or Repair ( ) an Individual Sewage Disposal
S stem at•
._... ,l o - -ckr --- v--- --- ---- • ----------
/�. a ocation-Address or of o
O ner i/ Address
a .--- -•---• -- -- ---- = <- `--------------------------------------------------------------------------- --•-------------
Y Installers Address
d Type of Building Size Lot......----------------------Sq. feet
U Dwelling—No. of Bedrooms__________________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons..__-____-_-_-___-_---.__- Showers ( ) — Cafeteria ( )
0.1 Other fixtures ------------------------------- - -
WDesign Flow............................................gallons per person per day. Total daily flow-------------------___-___--_- _.._._-_gallons.
P; Septic Tank—Liquid capacity............gallons Length................ Widtli.--------------- 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----------------------------------------
aTest 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__-_-_-___-___-_-_-._...
ODescription of Soil-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U U
V Nat cf Repatrs or Alterati —Answ w�en ap icable. __ . _ _lld ep---- -- - -- ------------
�—�7
>` greement:
The undersigned agrees to install th 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 ssued by e board of healtl
,#a')Sign Zj-
-
w
Date g/
Application Approved By---------- •• . ..°. ........... ........I/•r/�-��-1�
Application Disapproved for the following reasons-------------------------=----- ----........................................................................... ..
--.......•...............•••-•--•--••---------------••---------•-•----..........•----••-••-•...-•••-•-•-•---••-•----•-•---••-----.•--•---•------------- ................................................
r" Date �{
Permit No................................................
Issued..........................................................f
Date ("
l-
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HE4LTI-,,,,
AVVIiratiuu -fur Bifipoiial Works T amitrurtiun Urrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( )' an Individual Sewage Disposal
System at: ~j Ow
• ocation-Address or Lot _
O .ner Address
a ---•- S;;� •-----------------------------------------•----•--_---- •----------------------------••--•-------
M Installer d Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms._.........................................Expansion Attic ( ^) Garbage Grinder ( )
pW, Other—Type of Building _________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures --------------------------------------------
= -------------------------.-- ------
Design Flow-----------------------------------------..--gallons per person per day. Total-.,daily flew ,-w.-.r' �_.__._..._.....-_....----gallons.
W .
WSeptic Tank—Liquid capacity _.:._..gallons Length................. Width._---------------- Diameter___ Depth ---.
x Disposal Trench—No.____-__•-. - Width-. _.______ Total Length Total leaching irez--------------
a ___ s ft
P g gq
Seepage Pit No--------------------- Diameter _.__. .: Depth„below inlet ................_ Total leaching ar`e ____-.__:_:_ .___sq.Ya
z Other Distribution box ( ) Dosing tank ( '`)
►-,
Percolation Test Results Performed by:::.__:.-__':____________________
W -------------------------------------- Date............................=---------
Test Pit No. I................minutes per inch. Depth'bf Test_Pit::_________..___.._. Depth to ground water....____._____
(14 Test Pit No. 2----------------minutes per inch -'Depth of Test Pit---I...........:------ Depth to ground water.....:------------
------------------------------------------------ __
...1. S..rr.
Description of Soil........................................................
............ --------------------------------------------------------------------------------------------------------------
V --:
W Y� /^__�_.__.._..._ _
Natu of Repairs or Alterati —Answ when a scab f004_.__
U P" P -� ------ ._.... ._------------------
r�.� � - -------------------------------------------
greement:
The undersigned agrees to install th 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 n sued by board o?alWt I
ign - -- • ............................ r r
' / Da e, �f
Application Approved By----- _: ._ - ----•-- f ?�'
,.
Date
Application Disapproved for the following reasons:................................. ....................................___,:_.....................................
------------------•-••---•----------------._. -.----------•.
Date Permit No.................................................:........ Issued.........................................................
Date
THE.COMMONWEALTH OF MASSACHUSETTS
'BOARD O HEALTH.
....re 1�?V..?.d.....::.....O F....... ...
Carr#i$ir�tr.oaf f�um�Ii�tnrr ��� '.
THI TO RT ; That the Ind du Sewage Di osal System constructed ( ) ors Repaired
by y
jj. A - =.. . . . . •....... .... . . ............................................ a,
A
r'
nst -- r -- --•-^'--• --
has been installed in accordance with the visions of Ar ic�l/e�X.I rof�The State S tart/ Code as desci ib�e in the
application for Disposal Works Construction Permit No.___---;4 -� ____-__-____-_- dated-J./`"__1a.'___77•.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL. FUNCTION SATISFACTORY. s.
DATE...-...... L ---------------------------•-•-•----•---- Inspector--- -,l
------ ----- . . . . .
THE COMMONWEALTH OF MASSACHUSETTS
.4 BOARD F HEA �
.�.. e
yes --------------
No... ..... ........... FEE. !...............
>aizi!f� k titrurti it r tt
Permission is er'eby grant ••--•-•---- .
to Construct or it ( ) an IIndividual wage sposal yst `
fat No..... / - --- ---------� �"' -----• .
•x� � � reet
as shown on the application for Disposal Works Constructio e it _-_-___ Dated----��..'___rZ_.`71:�......
I ___
DATE_ r Board of He Ith
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS