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THE COMMONWEALTH OF MASSACHUSETTS
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BOARD F HE L
2 ------.OF ....._..................................................
Application is hereby made for a Permit to Con010struct ( ' o6Re it ( ) an Individual Sewage Disposal
Systemat: � ---- � --•- •-- .. ------------------------------------------
Location-Ad s or Lot IVo:
r_l w Address
Installer Address J���[!////./fl Sq. feet
Q Type of Building Size Lot_. ._._ ,_ ._ _
Dwelling—No. of Bedrooms----------------------------------_---------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons____._.___---_-________---- Showers ( ) — Cafeteria ( )
0.' Other fixtures _
-_-_----•----•••-------•---------•-•-•---•--------------------•-•-----------------------•--------•-----------------------
W Design Flow..... _.. . _ gallons pe person per day. Total aily ow____________________________________........gallons.
�•-•-.----•-
WSeptic Tank— rqutd capacity------------'gallons th.__________ _ r 1 ._ ..._. . .. Diameter_______________ Deptll--------------_.
x Disposal Trench—�iameter
--- v�agyn- ----------------- e g Total leaching area--------------------sq. ft.
3 Seepage Pit No---- ____________________ Depth below inlet-------------------- Total leaching area....Z4_ sq.. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------- ----------------------------------•-•--•------•--••-•---•--.--•-- Date------------- --------------------------
,.-I Test Pit No. 1................minutes per inch Depth of "Pest Pit_.........._-------- Depth to ground water-._.__.--__-.__._...-_.
0�4 Test Pit No. 2----------------minutes per inch Depth of Test Pit--------------------
Dept17
ground water------------------------
P4 ----------------- --------------------------------------•-•---------------••--------------------- _...-----•---•-•------.....--•-----------------
0 Description of Soil---------------------- ------------••---•••-•...... -• .....,-- r ... -•-------•----------------------------------------
U - ------ •----• -----------•-•----------•----•--------------
W -•-------••-- ------------- --------------•-- ------------------------------------------------ -•--------------------------------•----------•----•-------------------------•--------...
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 \I of the State Sanitary Code— The undersi d further agrees not to place the system in
operation until a Certificate of Compliance has b n i su y the bo d of health. `igne J. 1/-- tor?Application Approved By -- -- ---- --- -- --•-• -• . ••--•---- ---- -
Application Disapproved for the following reasons:...............................------------_-----------------•--------------------..........................
.-----•-•----•------------------•-----------------------------•-•-•-•-----------------•---•--•-----------
Date
PermitNo......................................................... Issued........................................................
Date
• L e•
No. r- - - - F m� .., ........
t ` THE COMMONWEALTH OF MASSACHUSETTS '
BOARD OF HEALTH
_... ..... . . .. . .... OF .................................... .................................... ............
Appliratiuu -fur Dilapuitti Workii Tjawt trurtiun Urruiit
Application is hereby made for a Permit to Construct ( ) or Re 'ir ( ) an Individual Sewage•''Disposal
System at-� .r....
••. ---- ---�•... --- ----------------- -- - ...................
Location-A s or Lot No,.
...............ia ------------------- ............. -•--------- -----------------
------
---- ---------- --------••-•---------•--••-•-•---••-•---------------------------------•------
r� Address
--------•-•- . ... `--..... ------ -•""".......... ....................... .... ............•.... ......--•------•-•---
� Installer Address j" A
Q Type of Building Size Lot_./1/_V6 Sq. feet
U Dwelling—No. of Bedrooms______________________________ _.Expansion Attic ( ) Garbage Grinder ( )
--
aOther—Type of Building ___-.-___________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures -- ----- --------------------------------:---------------------------------------------•-----•---------------. .
WDesign Flow....... _ gallons p person per day. Total .•ily w--------------------------------------------
9 Septic Tank— iquid capacity ---.__ gallons 0th __ t 1 Diameter---------------- Depth----------------
Disposal
Trench— ___ e g i -: - otal leaching area q.s ft.
Seepage Pit No--------------------- Diameter......... Depth elow inlet_...... ...._._... Total"leaching area..__�Q_?;,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................
(� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Dept ground water------------------------
n; ----- ----------------------------------------•-----------------....------------•- ------------------.-------------------------.------
Descriptionof Soil-------------------- --_. ......_ ----------------------------- ------------------ --
V `:+
W = --- ------------------------' :;.._
----------------------------------------------- -
V 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 YI of the State Sanitary Code— T e undersi d further agrees not to place the system in
operation until a Certificate of Compliance has b n i u y the boa d f health.
igne -----
vol
DV
' Application Approved By----- • - . . .-----••--•------ f
Application Disapproved for the following reasons:-----•-•----------•---------------------------- ---------------------------------•----------- ---
----•---•-------•-•-----------------•------------------- --------------
Date
S
PermitNo........................................................ Issued...................................................
----------------------..
Date
�e
t� r
T E COMMONWEALTH OF MASSACHUSETTS
3 BOARD PF HEAAe:�&
D,/,,,,,,
........:....OF....- .. ..........,.......................................
Trrtif ird r of 01,11Mphaurr
THIS 1 CERTIFY i Ividu S wa isposal System constructed (iw4-"`'P\.epaired ( )
by =-- -------- --•-...--•-•---------------•••-•--
alle
at".......... --- - --- -- - - -- ---- " --- --- ---------------- .. -- -•--------------•------•--•---------------
has been'installed in accordance with the provisions of Article XI of T tate Sanitary Code as escrib.
application for Disposal Works Construction Permit No_____ ___ _____________1 ....... ... dated'
_ -.- .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU AN THAT THE
SYSTEM.WILL FUNCTION SATISFACTORY.
II ,
,. DATE'_ Inspector---------- ------------•-•----- ------.
E COMMONWEALTH OF MASSACHUSETTSr, +
BOARD EALTH
.t.
_..._.No.- .............
-- FEE---.....................
Dirivla lark C tru. 'nit rrmit
Permission is by granted_.... .---- -- I....�__.. .---...-•--•----•-•- ---- -----------------•-• --•-----------------•------••---••-•---
t
to Construct/ ) .or Repair ( ) an Individual S ge Dispos Syste
ji
at No. -
�' -
street
as shown on the application.f r Dis sal Works Construction -Pe it o. d----- ...........
• �' Board of ealth
{ r DATE--.. �. ,� ----------------------`'.............
FORM 1255 HOBBS & WARR N. INC.. PUBLISHERS _
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