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r'r THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
-- ...OF..... ....'...
Appliration for Biq aiittl Works Towitrurtton Vrruift
Application is hereby made for a Permit to Construct ( or Repair ( an Individual Sewage Disposal
Syst at:
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1
ati I rcs
............•.... Lot No.
-- - :----------------------------- ------------------------
Owner Address
Installer Address
d Type of Building Size Lot----------------------------Sq. feet
Dwelling k No. of Bedrooms_________ ____------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons..______----___-_---._.-_.-- Showers ( ) — Cafeteria ( )
a
d Other fixtures --------------- ------•---------------------------------------. ---•------•--
W Design Flow__ --------�O.......................gallons per person per day. Total daily flow_______ __ _____________------------------gallon`s.
WSeptic Tank Z Liquid capacity-/)�'�gallons Length------------_- Width................ Diameter---------------- Depth.---------------
Disposalx Trench—No.--___-_•___-_--.._-- Width................. t tl Tot leachingarea----.--__-_--..-_---s ft.
- �eI< v� -L �y_�__ 9
Seepage Pit No_____ __ _______ Diameter____ __ tal leaching arert.___..___._._____sq. tt.
z Other Distribution box ( ) Dosing tank ( ) � J.. ��
Percolation Test Results Performed by-------------------------------------------------------------------------- Date------------- ------------------------
a
Test Pit No. 1________________mtnutes per inch Depth of "Pest Pit-------------------- Depth to ground water-..-_-._.--_-.-_-_-____.
(_ Test Pit No. 2................minute .er inch Depth of Test Pit.................... Depth to ground water-.._-.-_.--__-___---___.
�+ ------------ ---- r % ..... ........................o ��..
-------------- ---------
Description of Soil A ••. = -- ='_ ................�/.�
U --••--•--•------•----•- ------• . ..... -•------•-------------•------••----------------••-------•--------
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
UNature of P.epairs or Alterations—Answer when applicable...-__---_-----------------------------------------------.................
•-----------------------------------•---•-------• ••-------------------------------••--------------------• •------------------------•--•-•-----•-•-------•-••------•--. ...... ----•--• --------
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 the board of hea. 1.
Signe �+�
� Date y�
Application Approved By......... .... ; ------------------------
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------------------•--------
---------------------------------------------------------------------------------•---•-•------------•-•-•---------------------------------------------------------------------------
_ Date
PermitNo........................................................ Issued.-- ...- -•� --!�................
Date
-----------------------------------------------------------------------------------------------------------------------
LOC-A_T_LO_N SEW o,G,E PERMIT WO.
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r� THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
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146 OF..... ... --------------
sliratinn for Di.4pusttl Worko Tonstrnrtion Verntit
Application m is hereby ade for a Permit to Construct ( or. Repair ( ) an Individual Sewage Disposal
Syst at �, .�..
.. _• _d- ti .._ ". ..._ .... • -----------------------------------------
1 .
.. ._...�.. --•-----•-•-
y ocat• n Andres or Lot No.
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Owner Address ;!
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f. t
Installer p` Address
Type of Building l ;r; Size Lot............................Sq. feet
Dwellin -�No. of Bedrooms.... _ Expansion Attic Garbage Grinder
g ;` --- g ( )
aOther—T'ype of Building ................... ..... ...No. of persons...____._. '+ Showers ( ) — Cafeteria ( )
Other '.'fixtures ...._ .._.. ------------------------- ---------- -------------
"707
W Design/Flow .._____ �.......................
................. ..gMons per person per day. Total daily,"flow _-�p ___ __-.----.._gallons.
U Septic Tank i-Liquid capacity .__.. alloris Length________________•Wrath- met
_-_-- .-..----_ Depth. ..._ ..-. --
xDisposal Trench—No Wid i o th of -- ing area--------- -- ------sq. ft.
Seepage Pit No.. -._._... Diameter._/_�. 9r t .................. Totalh r area __.---___.-sc it.
c _ - 1
Z Other Distribution.box ( ) } `Dosing,tank ( ) p loC� •
Percolation Test Results: Perforri<red by-------- --------------------------------- ._..,-....... te----------------------------------------
; Test Pit No. 1........:,_.:'._minutes per inch Depth of Test Pif:...................bepth to ground water..---__--_-_--.--.---.
LL, Test Pit No. 2.........! ..minut e.r inch �Pepth of Test,Vit---------------------Depth to ground water--------------------- -
M
o Z
Descrr tion.o€-Soil.- "` ';. ...•----- "..i. �--�---- .. _ _
-
W '"
� M
-------------
V Nature'of Re ars'or Alterations—Answer when applicable______________ __ j......._...___.
,
' ----- 5.................... ......•-•-----.--••--------••-•----•-•--------•---------.........................................................................
l Agrepe pent:' L' r
The undo gLnedj'grees to install the aforedescribed Individual Sewage Disposal System in accordance with
a the provisidlisl`off ,ticle XI of the State Sanifary,,;Code•—The undersigned further agrees not to place the system in
og'erationlntrl Certificate of Compliance has been issued the board of hea
fx Size
gne _.....
t Date
!API cation Appwroved ByQ-�S'- ?_..f�..--••
fig. - Date
J�f. Application Disapproved for the following reasons---------------------- -•= : -------------_-----------------------------F-•------- ---------------•-•-
Date
..,^Permit`No...............-----•-•-•--•-----•------•..........-•--- Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
n BOARD OF HEALTH
'ITertifirnte of Tom linnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by • ----------------------------------------- ------ =• •--- ......
' st r w ]�
at '/z �' ----------------
d
has been installed in cordance with the pyrovisions of A'r o Th S ate Sanitary Code as descri ed in the
application,for Disposal Works Constructi.on Permit No....... .. dated.../ . .... ...... .�.........
THE,ISSUANCE OF THIS CERTIF�E *T-EtSHALL NOT BE CONSTRUED AS,•A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE: --=-------•---••--•---_.-- Inspector-----------------------------------------•---........._........---•-••-•-•-..--•-
THE COMMONWEALTH OF%MASSACHUSETTS '
' ''•
BOARD—OF HEALTH F
44.
.... ( ..:...: f.JF......... � : ....................NO.. FEE jf'
y ,/ J /..-.
Dispgfittl Warkii Qlunstrurtion Permit
Permission is hereby granted.........................................:............... __________
----:,(Ace
at No
to Gonstr t ( ) or R p (. a ndv d al a ag As5sal�Vstem
Street - -•--- +. .....--"•----•----
as shown on the application f r ispo Works Construction mit Dated___ �'_ �, _
--•- �• •..... --.......................................
Boar o
DATE - ...................................... --------------
FORM 1255 HOBBS & WARREN. INC.. PUBJLISHERS
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