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No.,r-�;3..... ......
..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Q.(0 kL/- - --------------OF......61VAAesr
Applirat ion for Uhiposal Works Tonstrurtion Vrruift
Application is hereby made for a Permit to str ct (4'<O,—r Repair an Individual Sewage Disposal
System at:
... .... ..... d..........�.!.................... ------ - -------- --------------------------------------------------------------------
Lwqion-Ady�ss ---- tr or 4No
.... ............................................
............................... ...... ......
sr
caner A d ss
--------- .. ... ... ------".0............................................. ..................................................................................................
Installer
jp Size
Type of Buildinv Lot............................Sq. feet
2 No. of Bedrooms,_____________
U ...... ..F_Xp
Dwelling ___________________Expansion Attic Garbage Grinder
a
Other—Type of Building .......................... 0. of
persons........................... Showers Cafeteria
Otherfixtures -----------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow_
---- gallons per person per day. Total daily flow--------------------------------------------gallons.
Septic Tank Liquid capacity Length________________ Width___.___________ Diameter-____.__.___--__ Depth__._________.:..
Disposal Trench No_____________________ Width.;-------- leaching area-----
,0.. Total Length_......._.___ ----- Total leach' V5...........sq. f t.
Seepage Pit No.....)-.e.......... Diameter..W/Af-..�-- Depth below inlet.......��o ...... Total leaching area--v-4-��. . ft.
z Other Distribution box Dosing tank
Percolation Test Results Performed by-------------------------------------------------------------------------- Date----------------------------------------
�-4
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___........-_____... Depth to ground water__._____________________
94 ------------- ----------------/................................................................----------------------------------------------------------
0
Descriptionof Soil-__________ --------------------------------------------------------------------------------------
x ---------------------......-------
U .........................................................................................................................................--------------------------------------------------------------
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U
z 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 i sued,4y the board health.
ign ... . ..... ....... ....... -- ---------
............. 1hzI
Application Approved By..... ------ .. -----------
Date
Application Disapproved for the following reasons:--------------------------7--------------------------------------------------------------------------
............I............................................................................................................................................................................................
Dat
Permit No........................................................ Issued----- �—/ /- 7-3..............
, to
...........................................................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......74
...............OF.......
Urtifirate,of Toutpliatirr
...IRE $ I TP CE&FYFY, That the Individual Sew.age Disposal System constructed or Repaired
by -.Alt . --
.......... -------------------------------------------------------------------------------------*----------------
at...... Installer
------------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of Article XI of The State Sanitary Code d escribed in the
application for Disposal Works Construction Permit No.................... ..... dated-----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----..../�-' 2 Inspector----P-cJ201.................................................
-j- ../�----------------*---------------------
—---------------------------------------------------------------------------------------------------------------------
No............"=k...... Fxx, ...... :
THE COMMONWEALTH OF MASSACHUSETTS � �• � '
BOAR® OF HEALTH ;
? r OF......r.
... -
l ;
s
` Applt atiou for Ropmal Worho C onotrurtion ramit
Application is hereby made for a Permit to Censtruct (111Or .Repair ( ) an Individual Sewage Disposal
System at +»
y
pr --------------- ----------------
q t Loc tion-A&jtess or
+t No.
' i e Owner A d ess
Installer Address
Q Type of Buildi Size Lot----------------------------Sq. feet
Dwelling No. of Bedrooms_______________ ".___..Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------_------------ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ......................................................•---------------------•-------....-•---•--•----•-----•-...---------------------•--•-•..........
W Design Flow................ Z ..........gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank, Liquid capacltyr_ii =#}'kgallons Length................ Width_.___-._._:---- Diameter---------------- Depth----------------
W -
x Disposal Trench—No ____________________ Wldth__ z Total Length..................... Total leaching area..._„ _....o__.sq. ft.
Seepage Pit No.-.?�»•...._...... Diameter. 44 ._' De
pth epth below inlet------.�,;,,_......._ Total leaching area---• ._5 .= 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----_--_-_-_______-._.-.
GT4 Test Pit No. 2................minutes per inch Depth of .Test Pit..................... Depth to ground water__---___--__--__-_--_--.
Q+' ---- =
Description of Soil- �"O P �% `, ---------------------------------------
x
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 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"ok health.
S 41Yy l
rim ,i
• .-Signed; : :.>,�t� ., -�` �=�----•-- ---- - -- -------------------•-
�+
Application Approved BY ✓ t _d�_ 7 ...........
Date
Application Disapproved for the following reasons:. ----•-------•----------•-------•--------•-•-•---------------••----
...-•••-•----------•----•---•-------------•-------....-----•••••--••-----••-•--•-----------••-•---•----------••----•••----•----------------------•-----•-•---------------•----------........-----•-•--•-
�! Date
PermitNo-----------------•--------------------•------------•---• Issued.... D. .
I
te
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......?.Gt,� ..OF......
..... ...................................................
T-5rrtifirate of Tantphaurr
IS IS TO CE TIFY, That the Individual Sewage Disposal System constructed (Al)"or Repaired ( )
by -. 1 m. -"--• --•-- ---- ------- ---...............................-----------------------------------------•---------.. .....--
o Installer
at ` 6 �----- ----------------------------- -----------------------------------------------------
k has been installed in accordance with the provisions of Article XI of The State Sanitary Code as descr'bedm the
application for Disposal Works Construction Permit No-------------------- r = dated---- ____ __ '.:...__.
THE 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
-..:....{.fir b1 -.. :. :./`'{ 7S, r N
............. ..... .. .OF..... �_. - Ku
.. �..
No.------� -•- -- .. FEE; , ..-------
�� n�i� � �c�tr�rttla�t rrr��t
Permissiota i hereby granted-_.�.. ,_a- l� ---•-----------•----------------------
to Const t t or Repair ( ) ad I�X ividual Sewage Disposal Syste
----------------
at No..-- ----r°•-w - f
"- Street as shown on the application for Disposal Works Construction Per No _�_____ Dated_ /mr "..............
-------- - -
'":? ' Board of Health
DATE...._..:, _ _ _
------------------------ ,,F'�
FORM -1255 HOBBS & WARREN. INC.. PUBLISHERS ,A