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—THE COMMONWEALTH OF MASSACHUSETTS
"BOARD OF HEALTH
Appliration for Biiipviittf Marks Tanstrur "tin Punfit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
f U
--Location-Addr ss or Lot
p �vnera Address '
Installer Address
UType of Building Size Lot__________________________Sq. feet
Dwelling—No. of Bedrooms.......
s ___________________ Expansion Attic ( ) Garbage Grinder
---
( )
WOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures -----•----------------------------------------•-------------------•--••---•-•---------•-•--••--•---•-•--••---•------------------•---•--•-•---••••----
WW 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.
l= Seepage Pit No---------------_---- Diameter.................... Depth below inlet.................... Total leaching area____---___-__-_-__sq. ft.
Other Distribution box ( ) Dosing tank ( )
-- Percolation Test Results Performed b _____________ Date---•__-__________________-__•_•--_-____
`LI 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-.___-_:___________-.._.
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Description of Soil......................................................................................................... ------------
V ---------------------------------------------------------------------------------------------------------------------------------
------------ _
U Nature of Repairs or Alterations—Answer when applicable._-/@ <3 � _�_'_/____xy.z-A-_s --
-------------------------------------------- ' - ------•--------------------------------------
Agreement:
The undersigned agrees to install the 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 been issued by th ar- f health.
• ----------Sign - ---------•••---------•-_.._... .s'`3 � 1
• q Dat
Application Approved By---- ---•-• --............. .. ate
Application Disapproved for the following reasons-----------------••---••----- -------------------------------------:---------------------------------•--
_ -•-•-•-------------------------------------------------------------------•----------.....:----------------•-•••_--••------------•-••------•••-----•----------------------------------------------------
�_ Date
Permit No................................................--....... Issued........g1.Z°��% -��--•--......
Date
THE COMMONWEALTH OF MASSACHUSETTS
F } BOARD OF HEALTH
. . r
F� �
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,NVVlir'ativaa for Ehap sal Workii C omitrurtiou r.nmit
Application is�.hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
§y,stem at
_ .
•------------------•----•..--------•----•----•----------------............--=---....... •--•.....•--••----•-•---•-•----•-••------•••-...................................................
` Lo ation Address +r or Lot No-
..............................................---.. ----......_.............................. `---............................ ........... ...
66, of -�, Address _
ram. a�T;; � .w-r�x 1
___________________________________________________ _____________ __________________________________________________________________,_..........._.___
Installer Address
Q Type of Building , Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms..__..:.................................Expansion Attic ( ) Garbage Grinder ( )
a
Q, Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( . )
P4 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 ( )
a Percolation
Test Pit Test Results '• erformed by minutes inch ' __ g per inch Depth of Test Pit________ _________ Depth to No round water_______________________.
�Lq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
P4 -----------------------------------•-------------------------------------•-------------•-•--------.........................................................
QDescription of Soil------------------------------------------------------------------•-------------------------------------------------------------------.-------------------------------
x . -
____________________________________________._____-_--__i......_......................•.............-_ ..._.._ - s. .
U Nature of Repairs or Alterations—Answer when,applicable._ee s 0__0_ �,.Z---_ _______. "-t�._....
--------------------------------------------------------------------------------------------------------------------------------------------------------------•--- .........._........------•---------
Agreement: ,
The undersigned agrees to install'the 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.been issued by the,board,of health.
- Sign ., ,�,. ` t � �.��- =��
-----------
....7.-. Dat
Application Approved By.... r-•�-• ....... 7 We ------------ ..--- -
,� ate" '.
�. Application Disapproved for the following reasons:.......... ...................
----------------•-----••--••..•----••..---••.•-••••-------•••-------•----•-•-----•-----------•-•••-•••••.•---•--------•------------------•--------------•-•----•---•-••••-•--......•----
Date ..
PermitNo......................................................... Isstted- - -------•------- ....-••--•......-
Date
THE„COMMONWEALTH OF MASSACHUSETTS
BOARD 0.1 HEALTH
.. _.O F...... .. '
Trrtifiratr of Tompliaaurr
NlliTHI S. 0. ' RTIF at the I idual, age Disposal System constructed ( ) or Re aired
byR ---•--. ........................
Insta
b .�^
at T , '=- - - -- -•x-----•--......-tea---�--� ..
has been installed. in accordance with the.provisions of Article XI of The State Sanitary d as d crt 'ed in the It
dated
application for Disposal V��orks Construction Permit No._..___ _.._..
f :.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE.THAY THE
SYSTEM WILL -FUNCTION SATISFACTORY.
DATE -------••-------------------------------------------••---•-•_---- Inspector ..........................................................................
THE COMMONWEALTH OF MASSACHUSETTS -
BOARD OF EALTH ,
....
.......OF................. .,> �.... .�,..._..
No.. FEE_ ...........
�-
Diapoli a1 rk on urtio�t r . it
Permission is hereby grante -- _-__ _ __s__.:.. :.
•---.
to Construct or Repair( � vidua ewa e Disposal 5 e
atNo:,f-^•-- ' -^-- ---• -- --. eet- -----�...-• -- - _....-------------�--•---•-----
as shown on the application for Disposal Works Constructieao
t N _______ _____&- ated.__.. 1.___.. __I_./k._..______.
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------ -- ------•-- ! !Cl.�.--
Board o. Heai'i .
��
•
DATE ---/
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FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS C - y