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THE COMMONWEALTH f-1GTH OFUA�S^CHU u TS BOARD ffii /'1 fl
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, pphrtttiou -for Disposal Wo7�)Sor
outitrurtiou Vrruuit
Application is hereby made for a Permit to Construct Repair ( ) an Individual Sewage Disposal
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Locat' -Address or Lot No.
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ll S��"""" er = j Address
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1_-1 Installer14 Address
d Type of Burldi Size Lot_ /__. ___Sq. feet
U Dwellinl� No. of Bedrooms------------------------- Expansion Attic ( ) G.zrbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures __
W Design Flow.. ..................:........:... ........ a ons per person per day. Total daily flow........ ----------.---gallons.
WSeptic Tank Li uid capac' v.. lons Length................ Width................ Diameter................ Depth-...__--_...-..
x Disposal Trench 7 No. ...�.._..... idth.................... Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No.__-________________ Diameter-------------------- Depth below 'nl ----_____ ---_ Tot )leaclrirrg< ett_._._. ._ sq. tt.
z Other Distribution box ( ) Dosing tank � %.
by
Percolation
Test PiTest NoRisults--------npnutesmea inch---De Depth of "Pest Pit.................... Depth to Date.............__._____._..___________....
P P p ground water---.-------.--------..
G Test Pit No. 2................minutes per inc Depth of Test Pit-------------------- Depth to round water__.__._.._-.----_---_---
. --------•--------------= ------•-••---•--- •----------Description ----
of Soil______________________________.�.___ '
= ...
x
W ----•----•------------------•----•------------------------------------•---------------------•---•----------------------------------------------------------•------------------------------------•----
UNature of Repairs or Alterations—Answer when applicable................................................................................................
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement: '
The undersigned agrees to install the aforedescribed Individual S wage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code e unders' n d further agrees not to place the system in
operation until a Certificate of Compliance has b �s y the bo h alth. r
Signed. - --------- ------�- - -- -----•- ----------------------•-------- ---••-•--
Date
Application Approved B --------- -
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PP PP Y-----`-- �� Z
�eAPPlieation Disapproved for the following reasons:---------- -------------•--------•---------• -•-------••-•--•------..----•--•----.--._...._...
-•................ -----•----•---
Date
Permit No.........................................................
Issued {
Date
No—at ..: FEE.................... ..W..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O.�F H EA
r
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Applirutiun -fur 43iuplafittl 10orkiiTowitrurtion Prrntit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
Syst
rooae4e�� .................................. ...................
Locat 4 Address P or Lot No.
,,�o �, /fig Address
a _.._.._' -A-42 V4- . .__...__ rr r .Yf.. ..�_A+'-i.Yi"'""'n""_.•--------- ---------•----------•---•----_..._..__.•_--------------
V -•--- -----i--• --------------•-
- instauer .... __________________Ex Expansion Attic Address zrba e p
d Type of Buildiin p ( ) Size Lot./__ g_n ...Sq. feet
U Dwellm r" No. of Bedrooms--------------- Grinder ( )
Other—Type of Building ---------------------------- No. of persons_---__---_______-_--_---_- Showers ( ) — Cafeteria ( )
d Other fixtures __ "_
------------------------------------• ---------------------
-a Design Flow..t. ,__, ::__._ �ons per person per day. Total daily flow___..__- /..-_° ........:....gallons.
WSeptic Tank Liquid capac v Ions Length---------------- Width................ Diameter-------.-------- Depth.._.___.__.__.--
x
Disposal Trench i-No. _-e :__,_..,- idth_r__________________ Total Length____._______.....__. Total leaching area_.__.._.____.._____sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inle 3 -------- Totaflileaching ea.. sq. ft.
Other Distribution box ( ) Dosing tank.( ) r `
aPercolation Test Results Performed by---------------------------------------- -. --_---__----___---_- Date----------------------------------------
Test Pit No. 1................minutes per inch Depth of-"Pest Pit-------------------- Depth to ground water.-----.._---.---__--._.-
G14 Test Pit No. 2................minutes L_.
e inch Depth of Test Pit.................... Depth to round water._.------__--_-_-_-_----
...................
O p
.................................................
Descrition of Soil-------------•--------------•- - - _- ----•----= ------------- ---------------------- - --------------------------------------------------
x
U
W --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
VNature of Repairs or Alterations—Answer when applicable...----------------------------------------------------------------------------------------- --
------•--•------------••---•--------------------------------------------•---•-------------•---------------------•-------•--•------------------------•------------•-----------------•-------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual wage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code e unders nod further agrees not to place the system in
operation until a Certificate of Compliance has be >z isstt the board p�=health. , ,
�4 Signed � � �* �r;r �� � � ....................
Application Approved B .....-=.'`PP PP y-------- ,A
Date
Application Disapproved for the following reasons:..........................................—� -------------------------------------_--------------.------------
Date
--------------------------------------- Issued---•--. - - -
Permit No......................................................... � . / 7- -----���:
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OIE; HEALTH
: 'o-,•..........OF..... .. .....
��rrtifirutr of Tlom rliaurr
TH IS TO CE 3TIFY t'the In vidual Sewage Disposal System constructed ( ) or Repaired ( )
by......... � ' ' � "=" --------------------------------------------------------------------------
stab ,l�,t�
.at...._ sc ._l_f�..€1'"" ? ": = f '� �,�'C ------b -----•-• --•-.............................................
has been installed in accordance with fhe provisions o Article XI of she State Sanitary Cededescri ,e- ,in the
application for Disposal Works Construction Permit No_________________ _, ____. ------- dated__._ , ° _ -------
TIDE ,ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector-------------------•---------•-•---------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH_
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........'�+` .�•..t"..-ate.. � O F............. ... f
Now ..........
Bi5vug u !T ugtrnf4 ion Prrmit
Permission jsjiereby granted_..
---- ------•..................•---------•--•------•-•---•--.
to Cons tru ( or e air an Individual Se ag Disposal ystem
a
at No.:. -----
Street
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Street ,,,,
as shown on the application for Disposal Works Construction P " No.. Dat d-_- sir ;?
----------- .+'�j Board of Health
DATE---ft/� --------
/.�..._
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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