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UPC 10271 *
No. H163V � Jo-
SST ctx`�
HASTINGS. UN
Via..................
THE COMMONWEALTH OF MASSACHUSETTS i�dEJ "1 I
®A R® HEALTH
�jj oF..........;F4 ............................
.. :....jY�
a` ` r Bitiposal Workii Tonstru rtinn' rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
....... N ..... ' ...._.. ... 'wis ...... .... ............................................. ........................................
Loca' dr or Lot
. N .
..., 'e"�� . .......! :.......�.. :.... _ '...................... ........ ry ...... Fu
Owner A dres
......................................................... ..........................oiv... - ....._ ..�_ .........................
Installer Address
Type of Building Size Lot..� �� q.......................S feet
Dwelling�'No. of Bedrooms..........? Expansion Attic ( ) Garbage Grinder ( )U :...................
p`4-, Other—Type of Building ...LAB!�!P.-.... No. of persons..........Znr:.. Showers Cafeteria ( )
GL, Other fixtures ...............................• . -•--••-• ---------
W Design Flow................ ....................... per person per day. Total daily flow._...._.......................gallons.
t4 Septic Tank—Liquid capacityt'..4tIZl.gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit Noj�D_CK Diameter.................... Depth below inlet..................... Total leaching area__,?.-$,'Zrq. 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-.--._-____-__-._._.-_--
f4 Test't Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
C4 ................. ....... ....
O Description of Soil---------------•------------ .. � ----......---...-•-------------.._.....--•--------------------•--•--......._..----••--••-•---------•-••-----
x -----•----••-----------•------------------------------------------------------•---------------------. -----------
W
x -------------------------------------------------------------------------------------------•--•-....----------------------------•---•----------------- .................................................
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— he undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' by the b (Voglh
Sig --- •• ......•-•••..... .......... ........
...... .................... •.................... ........
/ Da
Application Approved Bv........ .� ------------- e �f�
ate
Application Disapproved for the following reasons:........................... ------------------------------------....----••............--•••••-•..._...
.......................................................... •-------------••-••-••••••............-
Date
PermitNo......................................................... Issued........................................................
+ ./.
No. -------, Fx$.. _
THE COMMONWEALTH OF MASSACHUSETTS
30ARD P
HEA T
d'-''vt ot..... OF........... - - --------------------
. pphra#ion for Elifivusal Ovrku Tomitrrtrtiort amit
Application is hereby made for Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
.,, P . . .: ...... ..... _______ - c...............-----....... ..._,,,,_, _...,- ..............
/(,l ocation-Alldr ,, "" Pr Lot N
.,.. ..Ear- --. . . .... .. ........................ ,,..._.....__�' •,�...4.. ..=:..- ------------------
'en
Owner Addres
�►- J
;at k�?1!�.r .:....... , .. 1,1��hzs.......................................................
Installer Address
Type of Buildings Size Lot...._��:Sq _'feet
Dwelling No. of Bedrooms........... .............................Expansion Attic ( ) Garbage Grinder`( )
'q Other—T e of Building No. of persons............................ Showers — Cafeteria
04 Other fixtures _._..._
-
W Design Flow........................... .... ........gallons per person per day. Total daily flotiv.............. - ._____..gallons.
WSeptic Tank—Liquid capacity/ -gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Wi . Total Length.......... _ Total leaching area....................sq. ft.
Seepage Pit No....../............ Diameter.,. .
Depth below inlet......: ........ Total leaching area._Z.d..2.�q. 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-___-_-_..._-___-______-
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------_...........
PI' --------•- , -- . ....... ..........................................•---------------.............................................................
ODescription of Soil. • -_----- ----.-...,_„-----------------•--------------•-•-•------------------------------------------•-------•--•-----••------
x
v
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 aI 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.
gned.... .. ....... . ...... ............
Dat
Application Approved Byi....... ........... 7.
.' atteo
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------•-•-----•--••----
...................•--------...-----........•-------------.........------------------....................----•----------....-----••----------------------------------......------------------•........_.
Date
PermitNo......:............................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALT
z�..........OF.........�..
Terfifirate of Tootpliau rr
S TO ERTIFY, That e Indivi, al wage , isposal System constructed ( ) Or Repaired ( )
by..., ....�j �° .. ...................... ..............................._............
�.�i Installer l
at... ....Z-�-----.... ... --�--
has been installed in accordance with the provisions . Article YI of The State Sanitary Cody as des ribed in the
application for Disposal Works Construction Permit No......__ t. // U
dated -/- 7 '.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................:............................................................... Inspector..-•-- .- ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA '1'i
r � ,.............0F..... .-----..............................._...
r. io�xo� l ork� C� � • ort prm'
_ �A .,......__. ...... ...._,.,Permission i�/hereby granted.(ed...`_. _ c.__._.__g.. _p_.__.... , .
to Construct L✓ or Repair an Individual J�ewa a is osal System
at No. ._ .�.........Z.� ..i�.� ......._.4zl.... `............................... .....
str
as shown on the application for Disposal Works Construction it No. _ Dated........�..,��...... �-.
---- -- -- . 4 .....................
DATE...................................... ...---•.................................. Board of Health
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS