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THE COMMONWEALTH OF MASSACHUSETTS
BOARD.
�O�Fy HEALTH
.....OF.....L—..!....�."'...`".!'.1...1.
.........................................
Xplifiratinn -for Elitipmal Workii Towstrurtion Vrruiff
Application`is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Osystep at
--. .._ .
Location•Address or Lot No.
-1 ............................................................................
Owner
W Address
a
........
- ----•-• ---------------------------•---
Insta r Address
UType of Building Size Lot.................... Sq. feet
Dwelling—No. of Bedrooms.,._...................................... Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QOther 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----------------------------------------
a
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---------- -----------------------------------•------------•--------•----------••---------------------------------------------------------------- -------------------
V ----------'....................................................................................................... -----•_----_-_--_------•-•------------.•-----------.--------•--•-----------•-------
►W ..--••---------------------•------......-----------------•--_-------------------•-••--•-------_--.------•----- - _------------._--.- . -_-•----------
W 7
V Natur of Repairs or Alterations—Ans r hen applicable.. jG�C'Q - "..0 ------------
---- ------
. ----------------------------�--:-----=�-- --------
Ag eement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b is, ued by .board of h It
-1
Si ------ .•.. • �-._:. • = �h�------,. ..--••-
Date
Application Approved By-------- --- - A y---------------------•------- -------/ ._7_..7..-_.7. ..
Date
Application Disapproved for the following reasons:---------------------------------------------------------.......................................................
.. ...----•----••----•--------------••---•-----------...----•--•----•------------•....---------••--------------•--------•----•--......._
Date
PermitNo......................................................... Issued........................................................
Date
..7� r� _
.� °-s p.d
No. . � '� Fs$.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH
C -- ......OF.... ...R.................... ........................
} Appliration -fear 43hipmal Works Tatuitrurtion VrrnihN,,
Application is hereb made for a Permit to Construct or Repair an Individual Sewage Disposal
PP Y ( ) P ( )
Syste at*
•----•---- -
-• --•Location�Address or Lot No.
---- 4
y{sOwner ,.., Address r,
_ _____ _ `+.:_ �_.......... ......__ .._...._.._.._ ------------------------- ::.......................................................................
Inst er Address
Type of Building: Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.-__--" j ______________________tv__Expansion Attic ( )*j a{' Garbage Grinder ( )
Other—Type T e of Building No. of er�ons_____________
a YP g ._.._-•-•----•--•---•-•-•--• P �'-., ---------------":Showers ( ) — Cafeteria ( )
a
Other fixtures == '6 -•-•-- ............................`.
d r -------•----•---•---•----•---------------
W Design ,Flow................. __._gallons per person per day. Total daily flow................!.. .__.gallons.
9Septic Tank—Liquid capAcltu gallons Length --------------- Width.------ ._. Diameter___._................. Depth ............
W Disposal Trench—No I Width.:.::..............: Total Length------- _.......... Total leaching Area____ ,�,ns ft.
Seepage Pit No.....................
Dlameter _'___________ Depth below inlet_..._: Total leaching area.___ _ ._._._. .sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Perforiiied"`b_. `...............
a •-••...... Date---------
-:.. ,
Testh,Pit No. 1----------------minutes cinch !'Deptha;of'1est Pit...*................ Depth to ground water_ . _--- _ .--.---
f� Test Pit No. 2................minutes'per,inch Depth of°'lest Pit.__._.__......_.____ Depth to'iground water....._..__________. .
v
Description of Soil.----------------------------------------------
u ________________________________________________________________________k..............-`/ . .,._._..._ ....___.__-____-----_._--______-__-__-_._----..-..---_._i` .� _____________________________
M ______ _______ _ __ ____________________________________________________________ i.1_.. _____ E t---------------------- --------------
J
tV" NaturA of Pe airs or Alterations—Ans r hen applicable. ^l ?
----------
` -------- -------- --------------------- -------- ---�-------------- --
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with A
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 n I sued by board of yal
, . -- ..
St ;ed ------ - ..��
14
' Date i;
Application Approved BY G•h`'�s ( �z� 1 ram .---7-7----
-----------
.................•-------Date _---------- :
Application Disapproved for the following reasons:______________________________________________________________ __ .. .
;, ::jz.:. -• ----------------------------------------- -•------•------ ... -----------
Date
Permit No......................................... Issued---------- :-..
Date- ,
THE COMMONWEALTH OF'M'4 ACHUSETTS
w BOARD OF HEALTH,,,
Trrtifiratr of 101,11 liftaurr
TjF?7 I_S �O�ER Y, Tha �e In idual Sewage Disposal System constructed ( ) o ed Repair
- ------------ ...................................
� Installer
At---2� ................... -
.--�/ ----••----•---•--------------•------------------.•......--------•----•-------•----...----•---•---•------.....--•---•-------------
has been installed in accordance with the P/rovisions of : tic eiX-II of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No 1 �"
__ _ __ ______________ dated'..... "__ .`__✓_ .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A 'GUARANTEE THAT THE
SYSTEM Wly, FUNCTION SATISFACTORY.
/q -7 4b.
DATE f 1 ....7------•-- Inspector-•--•-••-�b .-• --• . , fir -- ------------------------
{,_
%j THE COMMONWEALTH OF MASSACHUSETTS
„�,.. .,.F.. BOARD OF HEALTH
Y
? ( : O F c -�-'-''^ .......--•---------------
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No. -�
= .•, .. � r�;t ......................
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Permission is hereby grantedZ � --'--�9'- --- <• •.......................................................................
to Construct ( r o�, eq�air ,--gr-tridividual-Sewage Disposal System
........... Street -----•......................................................... ...........:.�:
as shown on the application for Disposal Works Construction er rt No------------`-Z---- Dated--- 2--�- -v
DATE..............................................................................
Board of Health `^'
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
4/27/2020 ShowAsbuilt(1700X2800)
COL[�T IO SEW b C,E PERMIT Al(
DRESS
BUILD R'6 hAAE ADDRESS
DLl.TE PERMIT ISSUED
DATE COMPLI WIACE ISSUED:
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