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L I AGE �WAV F IV IN.STA , LE S N E i ADDRESS u H OR OWNER DATE PERMIT . ISSUED iV�f/V f(JJ DAT E C 0 M P L I A N C E ISSUED it 5 • �_ A � �. -\ ,..� � � � `y�` r �� 4, 1 jtj ,�', Y/ ,h � e�y/ J �� •� t i�r, _ � 1 No.........f .... FEs.................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® F H T 1...............OF......... ... .. a. . j Appliration for Mqvniial Workii Tomitrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: s f ..... ._._ ..... -- ----------------------------------------- -•----•---------- ................................................... cation: ddress or Lot No. ......-•--- --.-- . _ .....-••------.-•--•------•..... ......... .. r - ..................................... O e «yj / V ddress a -... .. -----•-----�................................ / .- Installer Address 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 ( ) Q' Other fixtures ................-------------------------------------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. P4 Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter__-_________.__. Depth................ 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------------------------ a --------------- -•-------•--•----•-----._........-•--•-................................................................ Description of Soil...... ... ........... U ---------------••••--- ••--•-•-•--••••---••••--•-•--••••••••---•-----••--••-------•••••••-••...._...---••---------------•-•--------------------•- W -•••-••---••---- -----------•-----••--••••..._..-••---------......-••-••......----•--•--••----------------------------- --- --,........•---- 1 �' ,� x U Nature of Repairs or Alter ions—A er when applica e.------ ____ ______ _____ ___________ ________________________ _________________________ -------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 1 T: <� p 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 e boar of lth. cam--- .: Signed.. . ..-- •-•--- -••-•--•-•-• ... ....................... ................................ . �A Date Application Approved B A.. - - -------------- -----------------._.._....-----------•-- PP PP y----—----•- Date Application Disapproved for the following reasons-.................................................------------------------------------------•-•--••••-•••--...... --••-•---------------------••----•-----------------------------------------------•-••........•••••••--- v Date' PermitNo......................................................._ Issued--------------------------=--=........................... Date 4/vAl No.........Zee..... FizB ...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® F H EAIJ� ------- - - - ...............OF......:. Appliration for Biaposal Work.5 Tongtrurtion Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ............................................ ....................I .. ....... .... ................................................... 'p.,cation Address or Lot No. ... . ............ ................................. ................... ................................... .......... ....4��............. ..... ..----------------- ---------- i ddre s ...................... ........... ......... ------Ir..... .............. ........ ........44AZI ........0.... ................................. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No.. of Bedrooms............................................Ex ansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria PL4 Other fixtures .................................................................... ............ ...................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length—............. Width---___--_......_ Diameter....._.......___ Depth......_..__..... Disposal Trench—No. .............. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter.................... Depth.below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) '_q Percolation Test Results Performed by.......................................................................... Date........................................ .4 Test Pit No. I.................Minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 914 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..____..._..........___. 9 .......... ........ ................................................ -- ......................................................... 0 Description of S 71- , I/--- oil......... ....... . ...... .. ............................... U -------------*.................................................................................................................................................................................. ... ..................... ------------ ------------------------------------------------------------------------------------ -------------------------- U Nature of Repairs or-Alterations—AWer when applica ........ ---- ----- ...... ------------------------------------ ............. IF ............................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE , 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 e bo;Qrof711.thr. 7 -;2 Signed ....... Da te Application Approved By..........�� 1 ---------------------------------------- Application Disapproved for the following reasons:......................... Date ....................................................................................... ......................................................................................................................................................................................................... Date PermitNo..............................:..........................I Isstie�....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS,...,',% BOARD OF HEALTH ........... ..........OF........... ........................................... .... (9rdifiratr of`-toutpliatta THIS IS ro CeAI ....hat the Individual Sewage Disposal System constructed or Repaired ..................................................................... by...vr..... ..4.......... ------------------------ I aL16 d ----------------------------------- at...:�n... . ... .. ............ ... .......ol has been installed in accordance-,wi the provisions of T 3ke S anita�y Code as described in the 5 of The S application for Disposal Works Construction Permit No.-- ------ 'd............ date ____ %_ ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEDJAS A GUARANTEE THAT THE SYSTEM WILL. FUNCTION SATISFACTORYi, �_-2—7—0c,W ....... ....................... ........................... V-------- ......... Inspector........ .c. ... ................._- DATE._.. ...... ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH oc .............. OF............. 1........................................... FEE........................ Disposal rh udion Vrrntit Permission is hereby grantej,,------ . . .............. - . .. ...................................................................................... 4 0 . Individual S 41spos st to Conspt .9r RepaV e 4 .4 --- ----!----- .... . .... ................................................... at No.. ....zk��. ............ . .............73?.... ../'. 4� 7 Street as shown on the application for Disposal Works Construction Permit ......... .. ..... ted......."-."?—A................. ............. �a ............... .... ...... .. ....................... Board of Health DATE ---------------------_-_- ........ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS