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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HE L H_ 61—
...... ......:OF........' ... .. - --------------------
A liratiuu -fur Ui� uiittl orkii Towi#rur#iou Vrrutff
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
Location:Address or t No.
.
' Gsi -----------
------- --
Owner ddress
�Wj G - e�i f �-----------------------------•---•-•--- -----L � y--U&.1�.--------------------•------
Installer Address
UType of Building Size Lotx/` ,., -------Sq. feet
�-, Dwelling No. of Bedrooms-----az................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building .-__---------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures --•--------------------------------------------------- ----------------------
W Design Flow__,_____v 70.........................gallons per person per day. Total daily flow_____ ----___-_-_--__._.......:..gallons.
9 Septic Taitk-tLiquid capacitv,l4 _'_e:gallons Length----------------,Width........-.------ Diameter---.__--- .---- Depth_--------------
Disposal
x Trench—No_____________________ Width-___---------------- To�_ elkw_�inle-�O*
d_ —Total leaching area_._--._.--_-.._---._s ft.
h g` q.Seepage Pit No__ ______________ Diameter_!A 't?._... Depth .. ........ Total leaching area---_----.-.___--sq. It.
Z Other Distribution box ( ) Dosing tank ( ) ��.
'-' Percolation Test Results Performed by. �'J ' Date.
a
,a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-.---_______----_N10th to ground water-.-.-__.----__--__.-._..
f� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water...-.----_--_--.-__-----
y-----•-• ---• -------- fF-- - -- ------ ---- --•-•-•---------•------••••_------- ". - -
Description of Soil 6 - ... - 'Z ----
xG - G_ —......-- - ------- - - --- --
W --------------- ------ � ..__ ......................... ____ _
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 Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ss ed by the rd of health.
a
Application Approved BY------- = .--••• --- - •--• _a......... � --------
AppliApplication '
cation Disapproved for the following reasons:-----•------------------ ---•-•--•---•-------------------------------------••-----•----•...-••-----•--
--------------------------------•--------------------•- -----------------•----------•----.-•--•---------------•--•-•----------------••-•---•-------------------•-------------••-•-------------.---------
Date
PermitNo......................................................... Issued...................---- •----•-r.............
•i�a�• � f
No. --.1..- ----•--- Ficx.//..................
THE COMMONWEALTH OF MASSACHUSETTS
62
BOARD F HE H y.� 7' �.
..-- .OF........
N.pfiration -fur Diovouai Iva
W# Cnutt tr attun rr tit.
Application ishereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
0
Location- ddress or t No.
Owner -
Installer
Address
U Type of Building ,,r� Size -:_.Sq. feet
Dwelling N No. of Bedrooms-_.-..raw---------------------------------Expansion-Attic (X) Garbage Grinder ( )
Other—Type T e of Building ____________________________ No. of ersons..___-__-------_------_-__- Showers -
0.�i YP g P - (- ) •. Cafeteria ( )
a
Other fixtures ---'----------------------------•------------------------------------------
W Design Flow........ Q..........................gallons per person per day. Total daily flow......X---_--._._--_-_-__- -.---gallons.
W Septic Tank Liquid capacity/tb9'kgallons Len
gth Width................ Diameter------.--------- Depth---------.._...-
x Disposal Trench—No_ ____________________ Width.................... T9 1 Total leaching area......_.__-_..______sq. ft.
ter'..
Seepage Pit No.�.............. Diameter/Am. d......Depth elow inle ............Total leaching area_-_----.--.-_____-sq. ft.
Z Other➢istribution box ( ) Dosing tank (
~" Percolation Test Rgsults Performed by....... Date----------------------------------------
Test Pit No. 1________________minutes per inch Depth of Pest Pit.................... epth to ground water-.-----.-..-. -------.-.
GT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
Ix K
-------_______t._..
O -_-------------
__ ................................../_. `y ,-.
Description of Soil_ -d 4... 0 {�
UNature of Repairs or Alterations—Answer-when applica e----------------------------------------------------------------------------------•.-.-._._.....
----------------------------------------------------------------------------------- .................................... --------- r-=--------------------=--------------------------------
Agreement
The undersigned agrees to.install the afor"edescribed Individual Sewage Disposal System in aecordance 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 bee };nth. rd-of,health.
igne .r •.......---------------- --------------
Application Approved By ... . = u { ............. � �
•ytci - `Date- '
Application Disapproved for the following reasons__________________________________ ______•--___..-------._..._--__----_•_--__-•---:•--•---•-,-----,,,-----_-....
{ Date-
fPermit No---------........................e........................ Issued............. ......................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9,Fn HEALTH-I
C pxtifir t of Tomph'aurr
TH CE " t the Individual Sewage Disposal System constructeor Repaired ( )
L
4installer t�` -(�aY.d�E - f s -----=
has been installed in accordance with the provisiorticle I of he State Sanitary Cod as de ribed,in the
application for Disposal Works Construction Permit No-.-_ ,,ri)"_ _ .............. dated..... 7. T
THE ISSUANCE OF THIS (CERTIFICATE;SHALL NOT`BE CONSTRUED AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .;
THE COMMONWEAH OF MASSACHUSETTS7,12
B0A2D r H E H rs
NOcd......A/ t
..... ..:...OF........ .....................
FEE ...............
Pin 0 n notrurtion "rrmit
Permission.is eby granted-•-- • _ .. ....... # f ------------------------------------------------------------ .......---------•------ _
to Construct ( or reiir an Ind' id al Sew Disposal Systent
at No.¢ ,�
_ Street
AV
as shown on the a lication for Disposal Works Construction. mitDated____ f_Z 7
.PP ,P
------ -----ON
Board of Health a
DATE.........---------------------------............................................ /
FORM -1255 HOBBS & WARREN. INC.. PUBLISHERS V
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