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Nov....LP..........
THE COMMONWEALTH OF MASSACHUSETTS
_ J BOARD O� ' HEAL. H
/.....OYC.I ..........OF..!�S J..� ��t/h/ . .....
Appliration for Mopmal Works Tonatrurtijan Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at............__.. A '....... °`�.cam^........., ...........................................................
. Location-Address or Lot No.
Ow er Address
staller Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons.............:.............. Showers — Cafeteria
Q' Other fixtures ----------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................. Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •---------------------------------------------------•--...
.......=•..........................................................................................
0 Description of Soil........................................................................................................................................................................
x
W •----•----------------•-•---•-•----------•-•--------•••----•----------•--•--••••••-----•-•-••-------•-•-•--•--- ••••- -. -- ------ - ---- ----
U Nature of Repairs or Alt ati ns—Answer when pplicable..___.: <_ ::._.. x -----------
I :::_
1�' �'o.. ----------------------------------------------------
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 issued b the board ofh%G / G `�
Signed_ t t/--..:.........��.�......------. �-r Q. -1-�5 ----
Date
ApplicationApproved By...................••--•-•--••.................-----------------•--•-••-•-••---------------.----• ........................................
Date
Application Disapproved for the following reasons:................................................................................................................
i
.................................•-•-•----•-•----------------------------•------•-------•--•--------•----•---•-•----•....-•--•--•-•---•------•-•----._.... .........C.-•-----••-•--••---......-•-_..
_ •-Date.m�'
Permit No.. Issued......
..._.�-r.... .
�_W----
Date
W--,_- --------- --- ------------- -- ---------------
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............................
Apphration for Diopoottl Works Tonotrurtion Pumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: S ( P
..................'Y...... =I�.�. .:�:�:`.:; ..:.::1-----.?h:.N!<-,-------- - '"T'f. '1,,a.^.:---=-C- ..........................................................
Location-Address or Lot No.
: .
r"1 Ow er Address
a .?.-•-./` ......'...4. I. ?.F...'.. ............................... .........•----------------................---...---------•-----------.. ................".......
�staller Address
Q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms......................... _.........Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ---•----•-•--•-.-•--•_
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter................ Depth................
x Disposal Trench—No. .................... 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 Test Pit.................... Depth to ground water........................
G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •---••-•••-••••••••---•-•---••••--•••••••-•••-•--•••••••---•••••----•••.....................•-•....................-••.........---••--•-----•--••-•--•-.--••-
0 Description of Soil........................................................................................................................................................................
x
U .---••••••••-•------•--•---•--•---•--•••---•-•••-•••-••••-•-•-----•---------------•-------------•._.......-••••------•-••-•--••••••--••••-----•------••-------••••--•••••••..........................•...
-----------------------------•••-- •••••••••-••••--••-•-•--••••••••••••••••••-----•-••••-•...-•••••------••-••--••-••............••. -
U Nature of Repairs or Alt ati ns—Answer when applicable.____Pr_+.-�—�!': ?.(�... -!! T ry--_.( r x,
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 heeg issued by the board of health.
Signed------==----= _ `-- :.._:�"......
- r ------
// r
Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:................................................................................................................
-----•-----------•-----------••••----••---••--•-•----••-•••••--•••-•--•-••................•••---••--•...•.•-••-•-••-••----•--••-•---••••••-•••--•....•--•-••-•••-•-•••-••--•-•••--•••-••••--•---•-•------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH nn
? .. ................oF.......... .r . / 1�!9�..................
f'rrtif irate of Tompliana
TH13S',��S`TO�`�y RT, V; That Vie, Indiv' ual Sewage Disposal System constructed ( ) or Repaired
by-..••-.tC.n_f_'_.:�•..+'`.5......�;, .../ /.,........Y ................. ............... ... .............._. .......................................
at_r_ �I .oI '•. .ter f+. �/ Installer
•,:� �/'j
e;r �� ��---"...--------•--------
has been installed in accordance with the provisions of Arti lejXI of The State Sanitary Code as described in the
a lication for Disposal Works Construction Permit No.. .....� � dated �_._../. � ._.�.�."".......•._..
PP P �:� � - --- •"
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU D AS A GUAR NTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
DATE.......... 2 ....72 .....j........ Inspector.....f. ............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALT
3
........OF....... ...>... .: ... �.,"•'""
., ....................... 7
No......................... ...............
Disposal Works Tonotrurtiun Prrmit
Permission is hereby granted...... .C�r-.....ex :........................................ ................. .....
to Con st juct (r ) or Repair (� an Individual SewageZIS,
al System
at No. K !. L.. ........ .e. �e; ... ------ -�.. �'---I.. 0.- .................................
1 � ., g� .
Street
as shown on the application for Disposal Works Construction- ermit .............I......... Dated.....'............. .............
...........................
___ _
A"' Board of Healt
)ATE.........2- 4:11 7.77" .................
FORM 12551 HOBBS & WARREN. INC.. PUBLISHERS