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No...._......VP........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O H E A LJ7H4
Appliratiou -for Disposal Works Towitrurtiou Vrruiit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
T- s A?a-
.......
- ----
2atron-Address . . or Lot No.
fr1------------'-----•--•.............................. ................••--------•--•--..._..........----....-•-•----•-•--------•---------------•----••--
owner ...............................•---•-.......Address
--- c ----- - ------ 5
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms-_---A-----------_-----------------------Expansion Attic ( ) Garbage Grinder ( )
`l Other—Type of Building je l'r.__._ No. of persons--------_ _----------------- Showers I — Cafeteria
QOther fixtures --•-----------------------------------------------------------------•---------- ------------------------------------------------------•---------•---
W Design Flow......' -"�'..................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacitv,/e?_,_-5ttgallons Length___-___•___._.-- Width................ Diameter........_.------ Depth---______------
x Disposal Trench—No- ____________________ Width-------------------- Total Length.................... Total leaching area......--------.-----sq. ft.
3 Seepage Pit No--------------------- Diameter____ ____ Depth below inlet.................... Total leaching area-------.----------sq. ft.
z Other Distribution box ( ) Dosing tank ( ) --
'-, Percolation Test Results Performed bY---------- ............................................................... Date----------------------------------------
aTest Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water..._.--.___-_._.__._. -
�14 Test Pit No. 2________________minutes per inch Depth of Test Pit__-_-____----_____- Depth to ground water........................
Ix --------------------------------------------------------•- --------------•--------- ..
Descriptionof Soil--------- ----------- lzp/.................... ---------------------------------------•-•-----•--------------------------------- ---.--------
x
W
VNature of Repairs or Alterations—Answer when applicable----------->-.1'_,5 ----------------------------- ____-----------
------------------------- _
Ir
...6_°..._G•a�, ���r � - --------------------------------------------------------------------------------------------------------
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 by the board of health.
Igne - --••-• ----- �------------------------- •---------•----•------_---------
Date
Application Approved BY--------- �-�-- ---- -- -- --------•- ----------- ... / _ 3 — 7.�
Date
Application Disapproved for the following reasons----------------------------------------------------------------•--.-•--.-•-------:---------•-----._._...--_----
.............•-----........__...._...--------------------••--------------•-•-••---•--•------------•---•-----------.........--•--...----•----•---••----------•---------•-•------------•------••-.--•--
Date
ermit No-------------........................................... Issued........f/------- =-=-G----- ...
Date
_416
No..................... Fmic .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0 HEM H /
4 !: ......
....OF........... ...a. ~. .. �4�
Appliration -for Uttipmal Workii Towitrurtion Prruid
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
,3
...... ---------
-�oca�tion-,----Address------------------------------------- ------------------------------------------or r*-Lot---No. ...... •
........................................................... ..............:...................................................................................
"Or ---- Address
.ta.Ier Addres
- ---------------------------- *-------- - -------------------------------- -- 's-------------------------------------------
Installer
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms------Q----------------------------------Expansion Attic Garbage Grinder
Other—Type of Building --- ..... No. 01 pet-solis--------. . ---- Showers Cafeteria
Otherfixtures ----------------------------- ----------------------_----------------------------------------------------------------------------------------------
Design Flow........77"77-7_777...................gallons per person per day. Total daily flow.......................•...................gallons.
9 Septic Tank—Liquid capacitv./,2_�)_/2gallons Length---------------- Width................ Diameter----_..-_.... Depth----------------
Disposal Trench—No. .................... Width-------------------- Total Length.-..---.------------ Total leaching area--------------------sq. f t.
Seepage Pit No--------------_----. Diameter.-_ .... Depth below inlet.................... Total leaching area------- ..........sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) ,
Percolation Test Results Performed by-------------__--------------------------------------------------------- Date--------------------------------------..
a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
r3:1 Test Pit No. 2---------------minutesper inch Depth of Test Pit........-..-------.- Depth to ground water------------------------
Ix --------------I---11---------------------------------...............................................................................................
0 Description of Soil--------- -----------6— /------------------------------------------------------------------------------------------------------------------------
�4
------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------I--------------------------------------
U 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 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 by the board of health.
igne ---------------------------- ................................
Dale
Application Approved BY-------- --- ---- -- . ........- ------------- --
----- ---- ----
Date
Application Disapproved for the following reasons:.....
...................... ..................................................I-----------------------------------------------------------------------------------------------
Date
PermitNo------................................................. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
✓FEZ ....OF.... ....................
"Trdifiratr of Tompliaurr
%Lk
by
THIS TO CEIMFY, That A, e Individual Sewage Disposal System constructed or Repaired
zx�_ -------
...... ---------------- ------ - - --- - ........................................................................................................................
at.- .... ........ ----—------ ---- -- -----------
------------------------------------------------------------------------
-
has been installed in accordance with the provisions 0 .,' r1fri XI of The State Sanitary Code as described in the
7
application for Disposal Works Construction Permit ----------- dated.----- _' ------ ----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A Gil RANTEE THAT THE
SYSTEM WILL FUNCTION SATISJFACTORY.
...... ..... --- Inspector...._. ----------------------------------
DATE........... —------7.
---------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD , F HEALTH
OF. .. OF--- .4......................
..............
No. ................ 7"�'�....... FEE.....L�.............
Di-spa,ial Workii CIT 1 marurpon Prrutit
Permission is hereby granted-._."'...-.. .. --------------------------------------------------------------------
to Constr c or Repair a......Mn :iv.idual S age Pfsposal System
-------------------- ---------------------------------------------------.........at No----�i
as shown on the application for Disposal Works Construction er it Dated..../ .-.. G............
---- - -- ... ........ .. _4.'�-- ------------------------------
7 -- oard of Health
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FORM 1255 HOE313S & WARREN. INC.. PUBLISHERS