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THE COMMONWEALTH� H EALTH F TS
BOARD
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Application is hereb made for a Permit to Constru ( or Repair ( ) an Individual Sewage Disposal
Sty ' ----'------- . •----....-- �--------------..
dre s or Lot No
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...... _ _. ..:.... ... .......... _ .. ...L....... ......._______.__. _ _... _ ....-- .................................................
ner ..-----.Address
Inst er Address
Q Type of Building Size Lot___41.4-0 _1.__ Sq. feet
aDwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q Other fixtures ..
----- -- ----- -
Design Flow............:.... 7_____.___ allo per person per day. Total daily flow___..._....._.��............................gallons.
W (� ------
WSeptic Tank Liquid capacit/ ...__ gallo s Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—Noff____________________ Wid h._._......__.__ _ L -.---. --__- Total leaching area....................sq. ft.
Seepage Pit No._....ti(;.-........ Diameter _ e be nlet Total leaching area_________________sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date----------------------------------------
W
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_____-_________--..---.
fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-__-____________._-..._.
W - ---------------------------- -• .............. ---
O Description of Soil____________________________________
--------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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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 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 b t board of lth. a
Signed----- -•••-•----•-• - --- ---------------- ................... :_........
Date
Application Approved By..---- 4
ate
Application Disapproved for the following reasons:--------•---•--•---•--- .......................................... •--••---------
----•-------------•-----------._. r------------
Date
PermitNo......................................................... Issued- --` .................
ate
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4
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® RF
HEALTH
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..................."-------------------------------
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Appliratiaan for 431spaasal Varks Tonstrnlrtilan rumit
Application is hereby made for a Permit to ConstFu9tor Repair J ) an Individual Sewage Disposal
Sy,pem at: jI ,
_ a - - �.``�- ..........................
-------- t' . . _ --,�� -- ..............................................--------___---------
s~ Icfon-tY dr s or Lot No.
f L- �`. •
_____ .ry ______.__ ____ __________________________
p; Qivn r Address
------------------•... ........... ......
Installer Address / �s.,+ +
d Type of Buildii� / Size Lot.... _. . ____Sq. feet
U t�
..� Dwelling—No. of Bedrooms.............._.............................Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building p ( ) ( )____________________________ No. of ersons.__.________________.__.____ Showers — Cafeteria.
Otherfixtuyes ---------------------------------------------------.......................................... a._ -
6,00
W Deslgn Flowe_________________ ____________ all( s per person per day. Total daily flow_____________,____:________________________ga
llons.
(� Septic Tank/— xt
Liquid capacit _:_:___._gallons Length________________ Width---------------- Diameter---------------- Depth------y.........
Disposal Trench—Nq____________________ Wid h...............,g ' t l L, , -awe.;k,�_��Total leaching ..................__sq. ft..
Seepage Pit.No...................... Diameter_�_iG "___ _. lle�i beloinlet____________________ Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY------- --•-------•- •------------------•-------•--••--------------------- Date........................................
a Test Pit No. 1................minutes per inch Depth of Test Pit:___________________ Depth to ground water_____________________._.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water________________________
------------------------------- -- .. ---------- --------
ODescription 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 be p issued bit e board of health.
�.
p Signed u� _-- Date
Application Approved B ` - ,,._-- -�="_._- .t-- -- ---- ----� '--
PP PP Y------
ate
Application Disapproved for the following reasons_________________________________________________________________________________________________________________
---------------•-----------------••-•------••-------------------••------•-----------------------•-----...---------------•---------•-•---------------•--. «--•----------------------------------------7 Date
PermitNo.......................................................... Issued..:d--------..... ....._. ....--'---•----
f Date
THE COMMONWEALTH OF MASSACHUSETTS
«� BOARD � F HEALT
. �`. .......... ...OF..... ..` . ... '......'.... ... .
Tntif iratr of. Taantpliaurr
,THIS- S T "RTIFY, That the In,ividual Sewage Disposal System constructed (Z or Repaired ( )
-ter° �� .
bY---.•---rip�"'------•-y� x. f" J' r'`.} --�_ S'-°! `�---------- I taller
od
- --- - ---------------------•-----•-•-----•--------------------•-------------•-------------
has been installed in accordance ith the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----__ ...�_._____________________ dated.._._____:�_ib_`___/Z_. _______________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR�,U�D AS A GUARANTEE THAT THE.
SYSTEM WILL FUNCTION SATISFACTORY. �' y
,, .,, - _ ,y
DATE-...... ;: ..� �_z_4--------------------------------------- Inspector.-
THE
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No........................ FEE..... --- .....--•---
. .
Permission-is` reby granted=_::__ '__ _. °p�N_______ . -
to Construct ) or Repair ( ) an Individual Sewage Disposal System
` y T yl-0
at No.- ' 1Yi _ f '«-� `
+ ° - ».! street-.- _ -� -------'----
-
as shown on the application' 'for Disposal Works Construction 'Permit No�� _____ Dated __f
r yy
Btd of Health
.DATE--- =` == ------------------- -----------------
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FORM 1255 HOBBS & WARREN. INC., PUBLISHERS