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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct (Lj or Repair an Individual Sewage Disposal
--r 5.._/_
Type of Building Size Lot.. ....Sq. feet
Seepage Pit No./
Z Other Distribution box Dosing tank 3- 7 7
Percolation Test Results Performed by.......................................................................... Date................6::VZ-7.....
0 Description of Soil..
^
The undersigned agrees to install deaforedescribed Individual Sewage Disposal System in accordance with
the provisions ofTLI��� 5of the StateSanitary Code--The oodero� plsystemnedfurther | cca not to place the system in �
��� until C tificate of Compliance has been issued by
....................................... ................................ .
Applicationy--- __ ^__,��_n�" ____ �
| ' �^ u"�
� /��plu�dou for the reasons:---..---------''�----_--_.------.--------_-_-,-__..............
-_---__'--_---_...----__--___-----_---__-------_---'--------_..--.------_--_.-------.---------
Date
Pero
` ! Date
' .
�����
No............. FimB......................
THE COMMONWEALTH OF MASSACHUSTET'-T' S
BOARD OF HEALTH
.......... a-te . ....OF........ .._
Appliratiou for Disp- ool Workii Tomtrurlion Prrutit
Application is hereby made for a Permit to Construct (L,-) or Repair an Individual Sewage Disposal
4 o-r
Syste :!rsZ J
• .......... ............................. ..................................................................................................
ocation- t 0.
v.
......................... ....... ........ea ......
weer Address
.........................
-ins
I er
Address
Type of Building Size Lot..J47J 2!......Sq. feet
U Dwelling—No. of Bedrooms----- ------
� ...........................Expansion Attic Garbage Grinder 0A
Z
Other—Type of Building ................ No. of persons............................ Showers Cafeteria
0.$ r fixtures ......................................�.........................................................................................................
Design Flow.s.3�...............................gallons per per oniLgjday. Total d&Uy-flow..:�'�_X4?..........................gallons'*
s 1:4 Septic Tank—Liquid capacityl gallons Lengt4.J- 1r.6.... Width................. Diameter--------t�....... Depth...............
Disposal Trench—No. ...................... Wid .................. Total Length........... Total leaching aret:-:,----------------sq. ft.
Seepage Pit NoI4.000....... Diameter..&A: .... Depth below inlet.--/.0........... Total leaching area:!'......�*......sq. ft.
Z Other Distribution box Dosing tank, 3- 7
Percolation Test Results Performed by______________ :_-_-------.--................................ .......... ........I....................
'Depth to ground i�l Test Pit No. .:..:. ........minutes* per inch Depth of Test Pit_........_.___.____..D water------------_---_---
Test Pit No. 2.................minutes per inch Depth of Test Pit..................... Depth to ground water____................__..
P4 ................................L ZZ)0 A I ........... ....................�/.......
------------ ----------------------------------::----- ./
---?--
...................... ........Description of Soil............ IK, . ................
.................................................. ....................
44
............5...
................................................................................................................................................................I..........................................
U Nature of Repairs or Alterations—Answer when applicable__________________________;.:______:_-:_--_----__:_L -------------------- .................
........................................................................................................................................................................................................
gr
A eement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T IT TIS 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 boa of health.
Signed .
... ................. ........................................ .................................
�,7— '21-�� 7
Application Approved:13Y__-- .... . ...... ................. ........................................
Date
Application Disapproved for the following reasons:... ..................................--------------------------------------------------------------------------
.......................................................................... .........................................................................................................................
Date
1.
Permit No......................................................... Issued..... .... ... ......................
Date
THE COMMONWEALTH OF MASSACHUSETTS-
BOARD OF HEALTH
.........................................0 F............
..........................................................................
Trriffir' atr of toWpliancr
TIJIS IS,TO CERTIFYi-That the I ividual S, age Disposal System constructed ( ,) or Repaired
by.....;PO A��& Q....... WI V=..........fxl q ..................................................................I.......................
ins alhib
-------------- --- -------------------------------------------------------------------------------
*4
............#
at. ......—-------- ................
has been installed in accordance with the provisions of T rof The State Sanitary Code as described in the
application2. ,;Z/-__72.......
.....
for Disposal Works Construction Permit No.- ------- ---------
dated_..___ .—
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM PLL FUNfrTION SATISFACTORY.
40 Inspector-------- .................. .. ..............................................
I ........../t�.77-----------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH
2.
7
.........OF..........
............ ........ ........... ..... ..... ............... V........................
N(......../.4//� FEE... .................
rrntit
....Permission reby gra ....
nted... ...... .... ................. . ............ ...................................................................
to Construef (,7.) or 4 Repair (j- ) #-Ind ix W_ ual.Se Disposal y�t�m�c
.......................................................................
Street -7
at No...Tv:r .. ...
as shown on the application for Disposal Works Construction Permit .......... ---/Date .. .....................m.........
vll�
.......... ... --- ---- 4�./zz_ ............
1-7 'Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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