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No. 10334
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No...14A --- ' WgrE Fst�.... .
THE COMMONWEALTH OF MASSACHUSETTS
BOAFdD F HEA _ (!�
- �'%:. oF..... - -
Appliratioo -for Uifipoiittl Worlii onfitrurtioo VProiit
Application is hereby made for a Permit to Construct (� ) or Repair ( ) an Individual Sewage Disposal
Syst t: -
ocarion dre /` ot� No.
caner ,y
W / / y?A�f ..............�......... '� —' ......
_' .......................................................
ddre �
� .............. r, ____._.__•'Instal"le� �--�—^ �-- Address
Size Lot---------------- S feet
d Type of BuildrNo.
q
U Dwelling of Bedrooms__________ ___________ Expansion Attic ( ) Garbage Grinder ( )
----•-----•-
aOther—Type of Building ____________________________ No. of persons.__---_________--.._-__-___- Showers ( ) — Cafeteria ( )
d Other fixture____________ ______________ __
----------�j'
W Design Flow..................... .... ....... �. Mons per person per day. Total daily flow___.._.._._ -------------------------
--- _----�--�-----..__.._--gallons.
WSeptic Tank Liquid capacit _��p' allons Length---------------- Width..._. ........ Diameter------.._-.----- Depth.--_______._.---
x Disposal Trench—No..................... Widlli----- ________ otA�-pw-tTotal leaching area.__..___ __.___ q. ft.
P -Seepage Pit No...._ --_--- Diameter./�_e�_��_.._ eptinlet_.. .__ Total leaching, sq. ft.
Z Other Distribution box (� Dosing tank ( ) —
Percolation Test Results Performed by-------- ------ ....................... Date -------
,a 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 groun�wa�ter --___--.-.- -----•.......... . ..O Description of Soil------------- �' _
..........
�, ... ......--�'- -- ��'------------ --•-----------------------------------------------------------
W •------------------- ------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------
VNature 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 bb sued by the bgard of health.
Signe ------ -------••••---------------------••--------••-•--••------------. ..__ (- _....1 .-----
®
Application Approved By-------I-~ — ------ °
' Date
Application Disapproved for the following reasons------------------------------ ---------------------•------------------------------------•-•----••-•--•-----•--
---•-••-•-••-•••-•-----•--------•-•----------•------------------•---••-...-•----------------•-------•----•••-------------.....-------- •••-----------------=-------------------------------------------
Date
.. r
PermitNo......................................................... Issued.. .. Date - .....
04
No.--- Fizta.....�,.�............._
THE COMMONWEALTH OF MASSACHUSETTS
BOA R D q 4FH EAOF..... M ..
:. Appliration -for Uhipmal Work nntrnrtirin Vrrmit f
Application is hereby made-for a Permi to Construct ( or Repair .( ) an Individual Sewage Disposal
Syst
.
..........
cation- dre .a yo..or No.
wner Addre /
W
Installer Address
dType of Buildi Expansion Size Lot----------------------------Sq. feet
U Dwelling�No. of Bedrooms__________ ____________________ p Attic ( ) Garbage Grinder ( )
Othee—Type of Building -----_--_-- No. of persons----------------------------- Showers — Cafeteria
Q' Other fixtures ..
Design Flow- _______--_-•------ ----• allons per person per-.day. Total daily flow:............[--.�••'�----------------gallons.
WSeptic Tank Liquid capacitv��'�... allons Length.................<Width..-_-- Diameter--_------..---_ Depth................
x }
Disposal Trench= o_____________________ ��/id h.__..__:___.. �eptow
1-. '"I Total leaching area_._..... .. q. ft.
Seepage Pit No..... ►r__ _. Diameter_ -_. inlet------ --.�... otal leaching area._( _ q. ft.
Z Other Distribution box ( Dosing tank
Percolation Test Results Performed'bY..................._.----._---_-_____.-__.--._...____-_---__-_-_......... Date_-_. -
00
Test P-t No. I................minutes per inch Depth of Test Pit.,................... Depth to ground water.-._--.-._.---_---._--.
Test Pit No. 2................minutes per inch Depth of Test.Pit__.._._', --------- Depth to groun water...........
a,
r
O Description of Soil _--------- ._ � . . . ------ - -------
U ------•----••---------------------------- 4�..._--_��. -•--• : �'�- = =
W ------------------- --------------------------- ----------------=--=---------------------------------------------------------- -------------------- -------------------------=---------------_-------
UNature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------------
e
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 b sued by the b rd of health
41
Signe = ............................................ -- -- ---- ------Da
-- . --• • - ---- - - - - '-•---•...Application Approved BY--- Da te
Application Disapproved for the following reasons:.---------------- -:---+-------=
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF -hIEALTH
G :� .. .
Trrtifirate of T"an* i nrr .
TH-'S IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired- ( )
bY............................
•--------•-••------•---.....
... ...................-2---.-.-... .....
... ............. . .................................................................
/ Installer'
at '' . --f 4-•--•---•:I- - =_ia--�. _ r` . /:---------- -----=---- ---+- ------------------------------------------------------------------------
has been installed in accordance with the provisions of Article, XI of The State Sanitary Code as described in the t•;�.
application for Disposal Works Construction Permit No------ _._ --------------------- dated.:.............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS"A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--••-•-•---•----•---------------............................................... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H-TH
7 ......................�W..tJ
. ... .....OF....../"�.f�r . -/ p .............................
No....= ` FEE-=>'`•----------------
%spn ial lVarkii Qlnntitrnrtion Vrrmit
Permissioni ereby granted----------------------------------=-------------------------------- --------------........................................................
to Construct Repa�( ) a Individual �a Disposal System
at No_K_ -- Zr `C cif - ��
Street
as shown on the application for Disposal Works Construction Permit No--------------------- Dated------------------------------------------
.................
Board of Health
} DATE--------- .----------------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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