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No........... ..Y-.... us...... ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O i
. HEALTH OF............... ... .............................:
Appliratiutt -fur 43hipoo l Worko Totta#rurtion Vaniff
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
!k hl C L---R.0........ ...L!!±45-----------------------------•- .................................... ...................................................
Location-Address or Lot No.
Owner Address
r�.-•-•----•--------•-------••------•------•-------•---•---------------- -----------•-•-------- 5_&J!d.........................................................
� Installer Address
Q Type of Building Cr AAk►S a Size Lot..r�- .........Sq. feet
Dwelling—No. of Bedrooms----------3..--_--•_______________________Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ...................................
Q ...........:. ------
W Design Flow_______________ 'C__._._____..__..._.__._gallons per person per day. Total daily flow_.....__. ��-_-___---.----_.-.........gallons.
R; Septic Tank—Liquid capacity/#.®-@---gallons Length__-.9......... Width_.....S.',...... Diameter-----3........ Depth..?.'_-......
W Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area.------------.------sq. ft.
x
3 Seepage Pit No------I------------- Diameter.J_':p_if,0_'_ ?--_ Depth below�' let.... !_I.`. ... Total leaching area...0_/ _9...__sq. ft.
z Other Distribution box ( ) Dosing tank ( ) p I®• G ,2- / J"-77
aPercolation Test Results Performed bY-------------------------------------------------------------------------- Date------------------------------------
a Test Pit No. 1................minutes per inch Depth of Test Pit_................. Depth to ground water..-----.___.-_.._..__-
(14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water............------------
i --- .. .....•......--•.................It----------
oSoil
- fr
Descri tion of Soil-------
W
UNature 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 issued by the board of health.
t
Date
Application Approved BY............ ..,� Ira - -4�------- --------------------.....----------------
Date
Application Disapproved for the following reasons:.......................... -------------------------------------•---------•---------------• -------------------
.................•-•------•-----•--------------•-----•-------------•----...----------•---------------........----•-•---------•--------------------------------------------•----•-------------------------
Date
PermitNo........................................................ Issued........................................................
Date
No....... .............. Fay.-..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' _.OF.............. :.. .:. ... .
ApV irafto t -for Ri1yasa1 Works C owstrurtion Vautit
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
................................ ----------------------------------- g:�--•••••-•••••••-•---•••••••••••••••-•........•••.--
Location-Address or Lot No.
.....n f '�' •!Z-it F'••••••••-••-••••••••-•••• •-•- " y�` �/ Nc,tl _/ .............................................
J) Owner f Address
--•••---•------•••--•----•---••••••-•••---•---••--•--••-- --•----•---•--------•- d. _ _w..........................................................
Installer Address y
d Type of Building a A fl1.IS o "► Size Lot._ 2,._i�_7___^_______Sq. feet
Dwelling—No. of Bedrooms-----------_-______-____________________Expansion Attic ( ) Garbage Grinder (Aq
Other—Type of Building ___________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures --•-- ---------------------------------------
W Design Flow__________________S_.°_......_.._.._____gallons per person per day. Total daily flow-----------)e_0______________-_---_.__-gallons.
1:4 Septic Tank—Liquid capacity/- et_Q__gallons Length----i--------- Width------- ......... Diameter_--__-�1.'____ Depth---�_ ........ '
xDisposal Trench—No_____________________ Width----_------------- Total Length.................... Total leaching area_-_______-_-___-___sq. ft.
3 Seepage Pit No------I_------------- Diameter_./-rtap_:S_P-_ Depth below ' let____ 1 Total leaching area...�F_�-C-----sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) J.
Percolation Test Results Performed by-------------------------------------------------------------------------- Date-----•---•-------•--------------------
W
Test Pit No. I--------_-------minutes per inch Depth of "Pest Pit_______..___________ Depth to ground water--_-___--__-__-__--_-_.
i, Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water_..-_-_____-___-____--
a+ .r ---------------------
- --•- "- , -------- ,r r �'
O ``� -
Description of Soil lR e ✓ t? �t z>
W
UNature 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 \I 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 board of health.
tgned12 -------------------------------------------------------------
Date
Application Approved By........ W ,................... ---------------------- -----------------
Date
Application Disapproved for the following reasons:----=------
-----------------------------------------------------------------------------------------------
----•-•••.-----------------------------------------------------------------------------------------------
Date
PermitNo.......................................................... Issued..........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD `OFs 'HEALTH
......................................OF..................
... ............................... ........
Clrrtif irate of Q.Taintlifitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (J--j or Repaired ( )
by.................. -.....-•-- ------------•---•----••••----•••---..-••-••••••--•--------•---------••••••-••-•••-•-•••--•••-
Installer
at.....!W.:V1.........-✓®1't �------------li.�.,�_................. -_--- ....a 5------- -� -
has been installed in accordance with the provisions of _ c}e 1 I/,/�o�f he State Sanitary Code as described in the
application for Disposal Works Construction Permit No---------------je4��...........-_ dated-- ...7_"._��`.-7_7. __
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. 3 Inspector--
.................................
ctor -•__•_______-•-•-•••_••••_•-_••__
THE COMMONWEALTH OF MASSACHUSETTS
' -, BOARD OF HEALTH
/ -.. �........0 F......J ,�!1-.r�,"-•sue44,4.............
No. 1i FEE........................
%n w iaHUork.q Tlomitrurtioat Vrrnfit
Permission is hereby granted........ •J Q_- N-------------------- --•----------•-------------------...-._--------------•---------••-•---------••_•-___-_
to Construct (tom) ,or Repair (-) an~individual Sewage Disposal System ,
at No._ail_'V� 7 4A.A..---101 t--••-•••--------�_'! ----
'_ Street
as shown on the application.for Disposal Works Construction P it .................................' 7
-•-•---- -•-- Dated-----�
4 s�
Boar� _�"-------------------------•--
s' d of I�ealth
DATE...--�'_"_ /�__ 7- ---••----•-•-••-----•-•-•--••-• t=
i t
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �' - '