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FEs......................... .
THE COMMONWEAL:TH•.QF MASSACHUSETTS
BOAR® OF HEALTH
/�✓......OF...............
Z Appiiration for Di-gVuuttl Works Tunutrnrtiun tirrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
Loc lion dress or Lot No.
.-----••............... ............---------------------......................._......
Ownez Address
......
Installer Address
dType of Building Size Lot............................Sq. feo
V Dwelling—No. of Bedrooms.............--_.------_._.__.-_-•---Expansion Attic ( ) Garbage Grinder
Other—Type e of Building 1411 W-A yp g .,�_:_.._ ,L�No. of persons____________________________ Showers ( ) — Cafeteria ( )
a' Other fixtures ................ ...... .
W Design Flow.,,................. . :T_________ gallons per person per day. Total daily flow__._._.. ........... gallons.
WSeptic Tank•(-Liquid'capacity/ gallons Length................ Width................ Diameter_______•_.___.._ Depth...............
x Disposal Trench—N ..................... Width....-_.,........... Total Length.......... -_ Total leaching area--- _. sq. ft.
Seepage Pit No........7......... Diameter.........j®-... Depth below inlet...... ......... Total leaching area..-Z_ sq. ft.
Z Other Distribution box ( ) Dosink ( )
1.4 Percolation Test Results Performed by-_... ... �'__.._ �._____. Date. ....................... ......... ..
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.-______-__-___----_,__.
P;, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.........................
O Description of Soil
._.......___�_~_. ..�— .�.r.......... .... _...
x �... l2 -
U -- ------..... •-•-•----•--. ---•---- ---•--•.---• -----•-••-••-•-----------••.............•-•---.........••--
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 TIT? 5 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 he board of hea .
Signed_
Date
ApplicationApproved By...........................--••---•-•--•---.......•----•--•--•-------------•---.................
Date
Application Disapproved for the following reasons:................................................................................................................
----------------------------••-------.....-----------------....--------------------......-----•.•---------•••••••••----•-••---••---•---------------•-•--------......------•----••------------•-----•---
Date
Permit No.. .... Issued --- -1...........................
Date
No..1g.Q-, . .4.� ,• F>c$....., �C....... .....
THE COMMONWEALTH OF MASSACHUSETTS
B, /OARD OjE HEALTH
ti/.01,41.....O F..............411�e/r! .` ✓...G"..... '
'=Allp ira n for Uispaa al arks Tonotrnrnnn lltt
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System
Lo= ion res or Lot No. '
.7'; ..._!ems i`......._ ........-•---- ----------------------------
Owner Address
. ....- ... .......................................................
Installer Address
d Type of Building Size Lot----------------------------Sq. feet,
U Dwelling—No. of Bedrooms ---=:-:-- ---•-------------- -- 'xpansion Attic ( .) Garbage Grinder
p, Other—Type of Building ______:. No. of p .,Xpansion Attic
Showers ( ) — Cafeteria ( )
QI Other fixtures -------------------------------------------------"-ee
d
W Design Flow..................... `, '...._.___ gallons per person�pjer day. Total daily flow.......... '-4_-••-----.____._•-gallons.
WSeptic Tank--Liquid capacity./gallons . Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width...... ._........... Total Length.................... Total leaching area................___ q- ft.
Seepage Pit No---------j......... Diameter.......... &. 'Depth below inlet........6........ Total leaching area.._.2- q. ft.
Z Other Distribution box ( ) Dosing. {
- �-
'—' Percolation Test Results Performed by........ /._.. ._. q 1�ZS Date.J
W -.. .
1.4 Test Pit No:.I....:.::........minutes per inch Depth of Test Pit___________-----••- Depth to ground water.........................
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fs,oD
---------------------------------- - - ------
escrptono Soil................... -----
U ----------------------------------------• --------- ------ - --•---••-•-•-------------------------•---•---------------------
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 TITTLE 5 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 he b rd of 1
Signed......
� .M-r«•..�
" W.
ApplicationApproved By.........................................................................-••-----------•-------•• -•--•-•-•..............................
Date
Application Disapproved for.the following reasons--------------------------------------------------------------------------------•------------...•--•--..._....._
-----------------------------•--------•--••--•--•-•----------............----------------......-----------•-•••••-••-•-•••••--•- ••-------••----••••-•-•••••---•---•---••••......••-•--•--•--••••••-•---
Date
PermitNo................... -------------------------------------- Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
......74.�,/�/ BOARD OF HEALTH
!. .!!'.............OF............. ..... .
(In#ifirate Of
THIS IS TO CER IFY, That the Injivjdual Se z e osal System constructed or Repaired ( )
b ' '�"` -- ,�,----- •------------------ -•----------------
f Installer
has been installed in accordance with the provisions of TITIF 5 of The State Sa ary o e as'd ssc}`ibefl iri the
application for Disposal Works Construction Permit No......................................... dated'---�:_�,,..C-.�--_•-•___•_--_--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM 1Al L FUNCTION S4TISFACTORY.
DATE.......... - nh.... - -•-- --•-••---•-----...--- Inspector 1611C
Y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
3 ...........:::.®F..., 3,a- of................................................................
No......................... 3E `°-4.,... ........
Map a :. r , n� inn ermit
;0�rt
i ishereby granted ... k •- -----------------------------•--------------------•........---------•••......••----•-•-----•-
to t ) or ai�� a io al Sewage Disp System J}
at
e • ._... ...._ t
treet
as shown on the application for Disposal Works ConsP.ioPermmo.. . ............. Date?-. _ __ ..._......_.
_ � l ............. ------------ ---
// Board o alth
DATE ��._..'-. vv
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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LEGEND
�X*$TINO„j SPOT ELEVATION 0,0 CERTIFIED PLQT;" ;
Iw tl t� `CONTOUR p _
FwIN,l;$�IlpD"' S.P0T ELEVATION ;0 01 1-07 Z
O, C 0-N T O U R —:._. _ p
; f .F. PVC() BOARD OF HEALTH }!! IN
AGENT
SCALE
'r , g0 DATE=`; 4
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VREPGE ENGINEERING CO /NG',
-. C L I E N T .
_.. I . CERTI Y THAT, THE
,�QI$TERE[f� rREGISTEREDI JOB NO. �C�47 BUILDING HOWN ON `
LAND CONFORM TO THE "ZON:
(
,yn144EER4� �.. SURVEY0RS,J UR. BY ` '^3
? ; ' OF BARN TABLE , MASS ' ` '' , " °
' V4 MAIN Sr 712 MAIN ;T CH. BY '
� II I<IIIO'GTH,•MASS. HYANNIS, MASS
SHEET_.-0F. ..—.— DATE , REG. _LA ;p
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INLET LEACH//VG P/T nSS FT. SELVAGE ,D/SPOSA L SYSTEM 7�iBULATlON
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> J30 SO/L TEST
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RESERVE LEAC'NING AREA SQ. FT. �
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