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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
------.Tcywn..................0F. Csr►rns... .......a........-----------...........----•----•-------.........`��
. ppliratiun for Uhipati al Workii Tunitrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair (yC ) an Individual Sewage Disposal
System at:
w114...........................•-• ..................................................................................................
Location:�_3t,
ess or Lot No
.Grsa. OP.= -----------------------•-----•---. ...13.t. . Qd !tbllK
Owner Addr ss
a 16.. �Zmlo----•--------•-------------•----.....--------------•--...........---.. SsS tri `5' � Vie*. -l�cHdQ
Installer Addre
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of .Building ............................ No. of persons.....................---.... Showers ( ) — Cafeteria ( )
a' Other fixtures ---------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
R: Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter_............. Depth................
xDisposal 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
f3, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...----.--------.------.
a ••--•-•---••--------•••••--•----•-•••--•--•--•••------•--------------------------------•------...---........................................................
0 Description of Soil........................................................................................................................................................................
x
U --------------------------•---------------•--------••-•------------------------------------•----•-----------------•-----------------•------------------------------------------------------••-••--••-••-
W •--•••-•-•------------------••----•••---••-•--•-•-•••-•---------------------•---------••--••-----•------••-•--•------------------•••--••••--------- ---------------------
VNature of Repairs or Alterations—Answer when applicable!tn ..--Sodo- _�r�pwi&__ ________________________
•---------------------------•---•-----•------••--•-•----•--•-----•••-----•-•-•----•....---•----•-----••-----•-••-••-••---•--•--••-•--•--•----•••--•--------------------------•-•-•--•..............----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI I. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beeenn issued by the boar of health.
Signed-- r_A?v..�le�---- ...... ......................... ----•- --- ��y���-------
Date
� Application Approved By............. ...y ...,,..�..,e�................................. ........................................ i
Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------••........
•---------•----------•------------------•-------------------------------••------•--------------,y-...........,_-----------------------------------------------------------------------------------------
Date
Permit No.... .7... �.3—•------------------------ Issued
Date
r
No.... .7 _a asp Fps. .....:...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Anpliratiun for Disposal Works Tonstrurtiun Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
t
. ...................................
•----•--•................... -•----...-----•----•------•-----.......-or Lot No.-- p v-+-.......
Loca2:on-Address ......__
.�..._r!_. .+r! -r+:�".r.._... ��^--+�l -t-4 L, riet r,tl +..�r�iSiS
...................... .....................•................___._..._.._......._...._........... ._.._..___.......... .'._ ......... _ ....__.__._...._ ...............
�- Owner Address
r
Installer Address
UType of Building Size Lot............................Sq. feet
I—+ Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water---__-----_-____-____.-.
fr Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------..................
a -----•-•-••--•----------•----•----•-•-•--•-••-.....---•---------••••------•.................•---••--......................................................
_..
0 Description of Soil.........................
x
W
VNature of Repairs or Alterations—Answer when applicable.�__:---.:.._.....`�" '" ,' '� *-
-------------•----------------------.....------------------------------------------------...........----•--------------------------------------•----------•-------------------------•-••-----•--•••••---
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of T iTY?7 51 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compiiance has been issued by the board of health.
t ti Y t! ..
Date
Application Approved By............� �._...._..r.... - -•--•--•-----------•na ......•--------
c
Application Disapproved for the following reasons:............................................................................
-••---•----------•-----------•-•-•-•----....-•--••---•----------••-•-•-•••----•------••-----•.............
Date
PermitNo....J5 ............................ Issued.......................................................
Date
`_� •.__ THE; COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Tnrtif irtttr pf: Tnntpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (14 )
byrY -----------------------------------------------------------------------------------------------------------------------••-•------_...•-
Installer
at �.�-tP-•--�__&... .......1.7------------------------------------------------------=-•----------------------------------•--•....................
has been installed in accordance with the provisions of Ti T E j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.-_?..7....... -__- dated-----------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
t C I- THE COMMONWEALTH OF MASSACHUSETTS
Cy, t' BOARD OF HEALTH
I� +� OF..
...... FEE........r,—..........
. Disposal Works Tunu#ratiun rrntit
Permission is hereby granted........ --------------
_.-----------
to Construct \,(I or Repair ( ) an Individual Sewage Disposal System
at No...........
T_...._.._..._.._.......
-- - --- -- ----- •--- .......----•----•--
Street
as shown on the application for Disposal Works Construction Permit No.,?Z.?SDated.._.....t?�- ---------------------
---.----- ��
DATE
L L �ard of Health
.SATE---------l--'-•�----1-----�---�-•----------------------•------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS