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V1 LTIWE I N S T A LLER'S NAME i ADDRESS GUILDER OR ' OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED Ale it THE COMMONWEALTH OF MASSACHUSETTS BOARD O} F HEALTH E A L JT H ...Fowl?..........OF.... . .��.l. .......................................... Appliraatiun for Uispaa al Workt Tunutrurttun rantit Application is hereby made for a Permit to Construct ( ) or Repair (1-r an Individual Sewage Disposal System at: tion ddress or Lot No. ........ ..'.......�_} L' . ------------=---------------------- :? .1.. .......................... O ner �..e----------•--•-•------------•-------- a Installer Address R� 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 ( ) P'' Other 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........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._.......:........... _.- P4 ----•• ----------------------- Cl O Description of Soil...........S�.�� �ML .-----..............................-............................................................... W xT •---•-----•------------- U Nature of Repairs or Alterations—Answer when applicable------- /...... ,1: ------------------------------- -- ----------------------............................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TA IL1;;^ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has n issued by the board of health. Signed.......u. ... Date Application Approved By...... ....... ---------•••--•-••--•-----•- -•-- Z Y' Date Application Disapproved for the following reasons----------------•---------•--•--•----•--•-----------•--------......---------------------------------------.....•- .............•..----......-•----------------------------....-•------------•--•--•---•---•----•••••---------••..._..••---••-•------•-•-••-•--•---•--•••--•••----••-••-•-••-••••-•-•••---••...----......._ Date Permit No................ Issued•-----....--------- --------------------•------......----•--• ....................................................... Date .a Z.-_..�-1a Fps THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --..... w _ ....................................... Applira tiun for Uiipuuaal Works Tuntratr#ion .e mi# Application is hereby made for a Permit to Construct ( ) or Repair (i--T an Individual Sewage Disposal System at: _ ..... ..� rf... ».! r°. � . ................................ ............................................ •- ..................--..... ......---- l " 1 { Lc}ration Address / y or Lot No;el prs4_ ' E _ I.a� �.. .: F ' f'�¢"d .s�" ."�� `7 .*sf ...^•ja�,. ......ns. - ... s. ........................ 5 j�' r/1 , r• ti r ONyner ✓ " �_...�... Address' W si • 9 i e�ff.�as�iC.. .... P r f' lr_ d f r + ;� ', s Installer Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons...::....................... Showers — Cafeteria d Other fixtures ---•-••----•-••--•......-----•-- - ..... . . .. . . W Design Flow............................................gallons per person per day. Total daily flow..........•...:..___......____......__......gallons. WSeptic 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. 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........................ -- -- -- . `----•---•--•------•-•----------------•--..........-•-•-•---•--------..•........----•-•-•-•--•----..... �. F �l t / •r; � ' '--•--•-•------------------•-------------------------....---•----------------------•--------•---••---- O Description of Soil FWi -•-----------------.----•---------•---•-•---._...•--------------------------•----------••--•-•...-•----•------•-- --- ••- - •-- -••-••-••••-••-•....---.------ U Nature of Repairs or Alterations.—Answer when applicable______. }_ ______.__. ---------------------------------•------------•-•----•------------------•----................------------------.........................................................;------.----------------- Agreement: The undersigned .agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT LE 5 of the State Sanitary'Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ---•- ------. •--... ...._Signed .._._.. ........ Application Approved By-----.:=: ............................. . ..1 Z-.-- ....��------ ........•... Date--•---........ Application Disapproved for the following reasons:............................................................................. --•...............•-•-------...-•-•--------------.....---.......-••-•••--•-•---•-•----..........................------......------------------------------------........................................ Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..... :. w ............. ... ................................ %rrtifirtttr of ToutpliFanrr THIS„IS.TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ) 7�r r.r � ,tom ,+. I s] ✓`} � r•r.F ..._a_..... .................................................. Installer has been installed in accordance with the provisions of TITL:: 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....&. °� /d............ dated................................................ THE ISSUANCE.OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 'L.. /I DATE......-•---•-----•--......-•---•-•--•....................f..._.IL� �`- Inspector . ------.. .............................. f THE COMMONWEALTH OF MASSACHUSETTS 4 BOARD OF HEALTH k , ............ ....,. ...... ... �.....t�............. r as f r No._ ............. FEE........................ �i��oo�1 ur�u �un�trnr�ion�. rrnt)i��n7,J Permission is hereby granted ...........%€ .. ............................................................ to Constr}�ct ( )/or Repair ( an Individua Sewage Disposal System ,••, , f Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... DATE_ VY ........................ Board of Health FORM 1255 HOBBS'& WARREN. INC., PUBLISHERS - '