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No...... ....-- �� AT Fss.. ..`�....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_ ......OF......... . ............................................
4 4� Appliration -for Diapooat 10orko C onotrurtion Puntit
P, Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
=' ----------------------------------------------- ...........�'lal. . ....:......................................................
W Owner : Address
< I.T....... ---------•----------•----..............................
I tallevr Address
Q Type of Building Size Lot----------------------------Sq. feet
U Dwelling No. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
G' Other fixtures •-------------------•-•--•--------------•--------•-•-----•-----------•------------------------------------------------------•-------------•--.------
d
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tarik—Liquid capacity------------gallons Length------_-------- Width___._.._-.-._.. Diameter-------------.__ Depth---.............
x Disposal Trench—No. .................... Width.................... Total Length------------_------ Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date----------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..--____-__- __-___---
fXq Test Pit No. 2----------------minutes per inch Depth of Test Pit-................... Depth to ground water__.__________-__--_---..
n+ •--------••---------------------------------------•----------------------....._..........-----•--•--.........................................................
0 Description of Soil-------------------------------------------------------------------------------------------------------------------------- _.--------------------------------------- ..
x
W
V Nature of Repairs or Alt_ tions—Answer hen a plicable---------•-f/.: ..-- w -----•---------•-------•-•---..
--------------------------------------- �"� t �--/...-...... � . .. C� = ...
-------------•-•--•-----•-•-•----
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 een 'ssued by the board of h lth.
Sign k ° ----•-------
Application Approved By------- -- . ........... •••-- -- . ---- � - �{ 6� at�.
-------•----....---• .
Application Disapproved for tl�ollowing reasons:._._____. ____________________________________________________________Date........__.__.
---•--•-•--...._..--•--•-•--••--•---------------------------•--•---------•--••----•-----•--•--•--••••-•--•------••-•----------------•----•------•---------••-•-.._......._--•---------•-•---------.-•---
Date
PermitNo......................................................... Issued........................................................
Date
1 �
No. ..-..-- .... Flc$... ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_. '`-----OF......... ..... . .. . ........ —
Appliratinn fur 11-sp sal Works Tonstrnrtinn Punfil
Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal
Sys at
Loca'o- Add-- ' �r or Lot No.
Address
s„r
staller Address
Y-
UType of Building -Size Lot----------------------------Sq. feet
.-I Dwelling No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
`4a Other—TYPe of Building ---•..... ...............•-- No. of persons____________________________ Showers Cafeteria
( )
Otherfixtures '"+------•----------------------------•----------------------•-- ...• ,:.:.�,..-
W
Design Flow___________________________________ ____gallons per person per day. Total daily flow-----------
_,*:_„_-',_....___...___._gallons.
1:4 Septic Tank—Liquid capacity_...._?s gallons Length ____ Width__ . Diameter_____ .......... Depth--_------------
Disposal Trench—No_____________________ WiZhli----------------__:_ Total terlg.th-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diaineterr_.................... Depth below inlef_ --------------- Total leaching area------------------sq. ft.
Other Distribution box Dosm"tank
WPercolation Test Results Performed by. =-'-:-'-=------------..__.____..._._...._,..__.__________.,-__.____ Date................__._.---------------._.
,a Test Pit No. 1----------------minutes per inch Depth of`�Test• Pit... _.______.__.__. Depth to ground water.__________________--_
f� Test Pit No. 2................minutes per inch Depth of Test Pit_____:¢_:_____..___ Depth to ground water.........•..............
--------------------------------------=- ='=--=-----------------------------------------------........................................................
0 Description of Soil------------------------------------------------•-- - ;-
x ----------•------------ ------------------- ---------------
V -------------------
W
x ----------- - ----- - -------- ------------------------------------ ------------------------------------ -- •- ---------------------------
U Nature of Repairs or A tion er hen a livable __ _ 4__
d
`� • --�t-----------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Santari ode— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha ee ssued the bird Ith. y
Sign - �+ - ".
Application Approved By----- .......... -• ---------- ••• ._ ..
to
y..
Application Disapproved for the following reasons:.......... .. ; ----=---.---••--•-------.•-.:-------••----._...-•-•-----
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Date,4
Permit No.........................................
Issued. :.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ^'r
,
l lb�
. ...J" OF......... 6. '...................
Q.1rrtifirate of Tomphanrie
THI TO RTIFY, T at the Individual S.4age Disposal System constructed ( ) or Repaired (' r
b ---------
.. 11 r,�J��
c�
at
' '' - +? ftiu--`------- ..........................................
has been installed in accordanct�with the provisions of Article'YI of.-The tate Sanitary Code s scribed in the
application for Disposal Works Construction,Permit No________________�_2:'��e..._.______. dated_._._ jg!
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST E® AS A GUARANTEE THAT TIME
SYSTEM WILL UNCTION SATISFACTORY.
DATE '7 1 � Inspector._.._.,. ..•-- Url&0 .�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�' .........OF........... . ' ...........
No........-•-•---••-•-•••• FEE...Z..............
%gVo,6ttl luuwkii Tn tr at rrmit
Permission is hereby g �r ed__e.'r:
to Cons u t ( ) o epair ( n Individual ewage Syst`
at No.-- - - "x R '"' Q (l -- x-------- ----------
eet
as shown onl,the'application for Disposal Works Construction Perm o:______, ktd___.__. ��
_
--------------- •----•••-•-------- .
DATE.,.--. .,
y /y Board of Health
7"
FORM 1255 HOSES & WARREN. INC.. PUBLISHERS `
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