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SMEAiEPING YOU ORGANIZED
No.10334
2-153L
MADE IN USA
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A- 1
No.�•�L ` / p�g� �� Fiic$.2,�................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAL H
r -.... O F....... ... G T
Applira$ion for Disposal Works Tonstrnrtio Vrrmit
Application is herebymade for a Permit to Construct or Repair an Individual Sew a e Disposal
System at:
----------------------------------------------------------------
0. _.. / ............ t
• -- .---
atio ess or Lot No.
s- Ow/p��r /� /� Address
PO .........I................ �j._.Ld.?...li(_� ---I`��4t9!c, St r✓/G&
Installer
Address
UType of Building Size Lot----------------------------Sq. feet
., Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------•--•---•--•------------•-•----------------------•----------------•-•----------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—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-_----_-_-____--______--
GX, Test Pit No. 2................minutes per inch Depth of Test Pit............_....... Depth to ground water-_---_--__--__--_---_._.
ODescription of Soil-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V •-•-------•"-'--------------------------'--------••••'•---'-----------------•-'•'•-.•-•---•--------•--••-••'•••---•••--••'•'•"'---------••-•"---------------•-------------------••-----------------.
W
x --
U Nature of Repairs or Alterations—Answer when applicable._--___ ___�_1�tr- oc ------".S we,4-_tv,�
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.
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 n i sued by the board cj health.
S d --- -----'Y_--a? —73
Date
Application Approved BY----------- ----- -------
Date
Application Disapproved for the following reasons------------------------------------•-----I
•--------------------------------------•-----------------
....................................------ •. ••. ----•••'•------------•""...--•--•'•-----••••---------••-•••---'-------•-•'---•-•---------------•-------------------------••--------......--"'
Date
PermitNo.............. ......................................... Issued........................................................
Date
11
a
k
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® QF HEALTH
_ ..........OF........ :. �`` >......-----
Appliratinn for U1.6posa1 Worko Tian.6#rnrtion Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair an Sewage Disposal
System at -
------------- ---- '�--....-- ---- -------.....................................
lion �uess or Lot No.
.A
Owns r / Address
a ...............................:��.7 -
Installer Address
UType of Building Size Lot............................Sq. feet
�-� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures .......................................................
Design Flow............................................gallons per person per day. Total daily flow...........................................°gallons.
WSeptic Tank—Liquid capacity............gallons 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 ( )
aPercolation Test Results Performed bY........................................................................-- Date.....................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water___-_-_-__-_-_..___----.
�Xq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ••------•-•-••-----••-•-----•--•----••••--•---•------•--------------••..-----------------...:_.•-------...
.-•-------------------------------------------------
ODescription of Soil...................................................................................-......••------••--------••--••-•-•--.....--------------------•--•.......-•••-.--•---
x
w
V Nature of Repairs or Alterations—Answer when applicable._...._ __ . ✓:_ ,�+ ?1., .: _7`3_ ?� x;,o '
---------------------------•--•-----•.....---------•-------•---•--••••-••-••--•----•------------•-•-----•----•--•----------------------•------••--•--•---•--------------------------••--•...•-----••---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article X1 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has n issued by the board 9f health.
................Date
r '' _
Application Approved B
Date
Application Disapproved for the following reasons:........................................
..........................................................
......-•---------------••------•-••-•----
--------------
Date
PermitNo.............. ......................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD: . HEALTH ,
-
. ... .....OF. �..
Cntt's
r�#t�irttt�e�laf
IS S TO CERTITY That ndividual. e Disposal System constructed ( ) or Repairedb44,4.---- --- - ., •--•-• --------- . .
.. -
-�, .yam,,. f aA^°''' In talr
�. , w
at "° f mot ? ' - . *V
has been installed in ccordance with the provis' ns of Art' e XI of The�,State SSanitary C as des ibed in the
application for Disposal Works Constructio . ermit No-----------
. .... dated_-_ _: .. -_- .i .......•..
n
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARAN EE THAT
THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----- ---•--. _.c3 - 1 -----------------•---•------ Inspector----'v
THE COMMONWEALTH OF MASSACHUSETTS
J BOARD F HEALT
------------ ---------------
No..:- -
\ FEE...
Permission is hereby granted.-- - --
+`1?r� iC _______________________________________________
to Construct ( ) or Repair ,.4 n Individual Sewage Di osal System
� * r ,
F Sheet '•. /"
as shown on the ap Iication for Disposal'Works (construction It No._! !:: Dated____ _....
ft rt " ` Board of Health
DATE... l • .........A!°
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS