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No......................... Fsa...L.TJ.:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OE
V.. -OF._..._..:..� �.. L� .................
Appl-iration for Uiipuiitt1 Worho Tonstrurtiou Punfil
( � Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
y� Sys at
....... ''_ __. ........ ._.'. _a. �_._"......... ....."'�_ ..................... ....................................s..............................
Address or Lo .
a
ner /res..._......._i__ ..Y...... �. .......°'•----------------------------------------------------- ___._...._------------ /•. .............................
Installer Address
d Type of Building '' Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons---------3.............. Showers ( ) — Cafeteria ( )
Pa Other fixtures ,---....- - -...
..
d
W Design Flow........... ... ......................gallons per person per day. Total daily gallons.
WSeptic Tank/-Liquid capacityld®-P�gallons Length---------------- Width----- ---------- Diameter..... .......... Depth_---------_..
x Disposal Trench—No ____________________ Width.___._.. __ _. Total Length_.___.___....___.._. Total leaching area_.__._.________._.sq. it.
Seepage Pit No--------/-------- Diameter.��''��_ epjh below inlet ---------F• To jal leaching area--------------•---sq. ft.
z Other Distribution box ( ) Dosing Tank ( ) �ca
�". Percolation Test Results Performed by--------------_--------_-- ............................................. Date---------------------------------------
a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........____..-.__.-__--
G Test Pit No. 2....._----------minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
-------
---------- ----'•
x Description f Soy.........`" _
�� t-----------�-- _7-
U ------------------------- �- %--... �f -- ??�
x --------------------- -- ----------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------
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 XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i y the oard of alth
_. Sign . . ._*
7S
Date
Application Approved B 7s�S
Date
Application Disapproved for the following reasons------------------------------ ..............................................................-..........-• .
------------------------------------------------------- ---•---•-----------------••--"-----------•-•-•"""'--------------'-------'---•--•-••-•---"---•---•......------------------'-----'------•----"----
Date
PermitNo......................................................... Issued........................................................
Date
No......................... Fim A�...'-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
L 'L OF.........-+ � .. ....... ��......T...............
ApplirFafion for Uiipuiittt Workii Tomifrurfioaa Vrruaif
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
I............b_4 ...........2,_---------- .. ................................................................................................
or'10 III
ner
a �` /////�JJ//•> `
Installer Address
UType of Building Size Lot____________________________Sq. feet
Dwelling—No. of Bedrooms...............:............................Expansion Attic ( ) Garbage Grinder ( )
P., Other—Type of Building ............................ No. of persons--------- --------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures -------------------------------'
W Design Flow............ ______________________gallons per person per day. Total daily flow------------ Y-------------------
WSeptic Tank 74Liquid capacityh4uvgallons Length---------------- Width---------....... Diameter_----_-..--__ Depth-_..--_---.----
x Disposal Trench—N� ____________________ Width...._______________ Total Length.................... Total leaching area--------------------Sq. ft.
-
3 Seepage Pit No_____________________ Diameter.l.- ---6�••dkepth below inlet........_.....,- . To al leaching area--__--._.-_--.-_-sq. ft.
z Other Distribution box ( ) Dosing dank ( ) O b - y".e- S 3 7S
aPercolation Test Results Performed by.......................................................................... Date.......................................
Test Pit No. 1________________minutes per inch Depth of Test Pit..-_________..____-- Depth to ground water---------------------
1:14 Test Pit No. 2................minutes per inch Depth of Test Pit..-_-___----________ Depth to ground water--.--._-___-__-._-__-..-
-
Description of Soil-------- Q ' -- ........- - --- ---- ---- �- }.... 1�J..---�-E_- - ----- �--------� � ----------------------------------
W ------------------------- ---------------------------------------------------------------- -- --------------------------------- -.
UNature of Repairs or Alterations—Answer when applicable.------------------------------------------------------------------------------------------_--
---------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witli
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 ipuetby the oard of alth
7s
Sign . ...---,-•----•----- �.�---•=�.� ---�-------
/ � Date
Application Approved By./' L - �... /— 7-S
----------
fir- --;-:f.----- Date
Application Disapproved for the following reasons: ----------•...............•••--------------------•--..........---.........-----
•---......••--------'----'-•-'-'•-"'------•'---.......--•----'-'---'-'---•-'-------•--------••-'---------..............................................-----------------------------•----•--------•----
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' .........OF......�T.. .................................................
N rtifiratr of TOmpliattre
)HII TO CE TIFY, hat the In dual S a Disposal System constructed ( or Repaired ( )
er V
at --• � /- '� --- ------- - --
�b
has been installed in accordance with the provisi�fis of Art' 1 XI of The State Sanitary Co as described in the
application for Disposal Works Construction Permit No._I� ,�
5----�--� ----------------- dated-f- --------. �---•-7-S- ---------
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 O,F7 HEALTH
61)/ ....... ........OF......... Z::...........................................
No. .. .------. FEE./ ..........
Ri at Work TT trurtion Vrrmif
Permission i ereby granted_ -- -------------------------------------
to Con t or pair an I u 1 a e Disposal X
em /'�/
Street — 1�
as shown on the application for Disposal Works Const action P it N .. _ ......../_ ..... Dated_._ .................................
.✓'�Gt �� ---------------------
o Id of ealth
DATE--------------------------------------------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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