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THE coMmgmvvsALr* OF wAssAc*ussrrs
BOARD OF HEALTH
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----.-' - ---'_'��F-----------_--------_________
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��0���lirmmww*� ��wm����iim� Works Toowptruwrtww«* Urx»»wft
Application is hereby made for m Permit to Construct ( ) or Repair ( ) an Individual Sm°ugc Disposal
System at: ^ �
- '---- ----_-'_--------_------_-'--.---------_-------
or Z11 No.
-__- ____ '-�'--__-
Owner ss
--- --'-----��---'�����---_--------------' -----------�r'-----_�����'----' ---------
�� o3d `� ' ` Si � Lot---.���- ------Sq. feet
� �� �o� of Bedrooms �urboX� 6r� ��r ( )Dvc
Other—Typeof Building ----------' No. of Cafeteria
PL4 ()dh,z fixtures
Septicns per erson per day. Total daily flow---- --- ------
- --- -'- -_,-_'��.."~ - Length................ Width Diameter-----. Depth------� �
Disposal Ircodh N ------------ Width-------------------- Total Length ------ Total leaching area------------ -------sq. 6.
8ceyugc Pit No --- Diametec-------.. Depth below inlet--------------------- Total leaching mcz-----..sg. it.
Other Distribution box ( ) Dosing tank ( )
~~ Percolation Test DomJts Performed by.---..-------------------------------------------------------------------- Date-..--------.---'
Iem Pi, No L----_-minutes per inch Depth of Test Pit--------------------- Depth 1oground water......------
Tes Pb No 2----------------minutes per inch DJeDth of
��04 --.-''-'— _- -
Description c6 SoU-.--------.--'-- J-3
����- -------_---�
V ---'----------'—'-'----'-----------------'---'--_--(----------'------------
----'---' ----------------------------------------------------------------------------------------------_ ----------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answerwhen applicable-------------- -� ----------........ ------------------------------------------------------ |
�
---'-----'--'-------'---------'-------'---------'-----------'-----------
`
Agreement:
_ The undersigned agrees to install the uforcdoscribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary . -- The undersigned further agrees not to place the system in
operation until u Ccc66coe of Compliance has been isXyed by the board of health.
------- - ---
ate
Ano�u6ou Approved Dy.-. ������
^^ �^ ` -- ^ n�"Application Disapproved .-
�r the fo8ox*��/ reasons:-----'__.--���_'.----_-__--_----._'-......^r--
................................................... ----------- '----------------------------
Da e
Permit ' I�o�' ��� �'
__-----_--'-__----.---'-'--' ---���,..����---'��-,_------
~^-''_'''-'_'_''---_'-''--'''''-''''-''''-'''''''''-'_'-'---_'-'-''''''--''-_�
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.............. ... .: .... OF........................................
_...
Appliration for Dhipviial Works Towarurtion Vrrniit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
• - . ----- -
ca on- ss • 4' or- t o
•+i'�... ..--....... ....... ---- - '---•• -`- -'�------------'. ............. ... ... --_-` -- . '._... . - ........................................
y a Owner • -s --
p Installer Address
UType f Buildiuv_ Size Lot_._._-____- ...........Sq. feet
.-, Dwelling No. of Bedrooms...•__.._..._ __________________Expansion Attic ( ) Garbage Grinder ( )
per-, Other—Type of Building -__________________________ No. of persons_-_.__._-____-____--__-.__ Showers ( } Cafeteria ( )
A' Other fixtures ----------
W Design Flow_,. ns per person per day. Total daily flow.--- - ---- - ------------gallons.
Septic Tcutlf/�Liquid capacity _. .__.. allons Length................ Width................ Diameter---------.------ Depth--.----_--.-----
1:4x Disposal Trench—N 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 ( )
aPercolation Test Results Performed'by....... ............. _____-------------------°......................... 'Date----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit_- ____________.-_ Depth to ground water.-.--_----_----.--.-----
f14 Test Pit No. 2-----_____......minutes per inch D pth of Test Pit.-_______._______.._ Depth to
_----------•--•----------------------- --'------ ----
D Description of Soil.............................................
------------------------------ ------------------------------------------------------------------------------------------------------------------------------ ------------==------------------
v Nature of Repairs or Alterations—Answer when applicable.--------------------------------------------------------------------------------I........
.._..
--- ----------------------- --------------
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 is ed by the Doard of health.
Igne -- -----. ---- ---- ------................... 4 `` l,-�`---...
' Date
Application Approved By..........:� .-•-• -'-''= . —'- -------- "--"----- ��� ...J-?
Date
Application Disapproved for the following reasons:................................-------------..............................................-....................
---•--...--•---"•--'------------------------------------------•--•-......--------------------------------••----------•---------•----------'...-----------•-•--...•--- ---------------------------------
Date
PermitNo-------------------------•---------•-•--•-----•--------.. Issued.----- -----�----�---•-------...------
D e
THE COMMONWEALTH OF MASSACHUSETTS
'1 BOARD ;02F :EALTH
.. . .. .. . , ........... .................
- � �rrtifir�tr gf f��aut�li�tnrr
IS TO �ERTI hat e Individual Sewage Disposal System constructed ( ) or Repaired
--- --------- -------------------.......
ait.
at ..._•-Yts� -•--- -----
has been installed in accordance with the provisions of Artile XI of he State Sanitary Code as described in the
PP P _..... --•4 4 - - -
a application for Disposal Works Construction Permit No.__.._._.._ `/ dated.. " .._.___
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST D AS GUARANTEE THAT THE
SYSTEM V+/I L FU �y1O.� SATISFACTORY. -
y
DATE------...-- ---••� Inspector----- -------------•- ....... . . ----"
Tk1E COMMONWEALTH OF MASSACHUSETTS,
BOARD OIP7 HEALTH.
__ FEE.N ....... - ..........
Wte
orkii � str r#ian Prrutit
Permtsston ereby gra ___,______�_�'______________._ __ --"to Constr ( or epairIiid v dual/sewage is os yat No.-- 5 �� __.
as shown on the application for Disposal Works Construction 'Pe No.__ _ -` ated_.Z /A/-_
��__.__..__
........................_
Board of eHealth
DATE.....-.............................................
" - FORM .1255 HOBBS & WARREN. INC.. PUBLISHERS. } - -
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