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No......................... FEE..... _,1............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -. _ F. HE�4`LTH
CS — `�- �
.........OF...-.. ---- ---------------------------------------------------
Applirattion -fur Uiapuutti Worho C onotrurtiuu Vrruift
4�6Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
syst . � 1��-
L io ddress or Lot No.
wner Address
a ---•-- -- ............ . •. ...................................... -----•-•••-..........-----•.....•--•••--------•-•..._.......-----------------------••-•••--••----.
Installer Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms_----------- --------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ------------------------------ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d Other fixtures - =
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--- _____A�ot Le h_ _.__.___ tal leaching arca_.__.__.__._...__._.sq. ft.
Seepage Pit No___ ______________ Diameter ..._. in t_......__...._._._..Total leaching area....___________sq. it.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY-------------------------------------------------------------------------- Date-.-----------------------------------
,_l Test Pit No. 1----------------minutes per inch Depth of "hest Pit-------------------- Depth to ground water_..---.-_____-__--.__
f� Test Pit No. 2._-_-_-_____•.__minutes per inch , epth of Test Pit.................... Depth to ground water-_.--.-.-_--------------
a' ----------------•••••• -----------------------------------•--------------------------------------------------------
Descriptionof Soil s ------------------------ --------------- -----------------------------------------------
x
W
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 \I of the State Sanitary Code—The undersigned further agrees n to place the system in
operation until a Certificate of Compliance has Issued b r t e bo of hea
1
ed.-. . --- --•••- -------
Date
Application Approved BYt1 1D 7,3
Application Disapproved for the following reasons:.................................................. ------------•-•--
-------•-•---•------••--------------•-------------------------•-------------•----•--------•-----------•-•---------•--------------•--•--•-----------------------•--------•---------------•------•--.-----
Date
PermitNo......................................................... Issued.......................................................
Date
--A— - _-
d7j
NO.�_`T l�......• Fss...21.... ..
THE'COMMONWEALTH OF MASSACHUSETTS
BOARD:�d_04_*L
F HEALTH 5Z Ira
-1 ---------OF..... .......................................................
Appliratinn -fur Uhipoii l Norkii Tomitrurtion Vrrmit
Application is hereby made for a Permit to Construct (4TO00r Repair ( ) an Individual Sewage Disposal
Syst
t.......... ........
r
c io Address or Lot No.
.............. ...............................................
wner Address
a ........... -------------....................... -------•---------------------••--•--••---•-----'•--••---•-•----•-••-•--•......--••-----•----•-•-•.
Installer Address
Q Ty e of Building Size Lot:...:............... ......Sq. feet
U Dwelling—No. of Bedrooms--------- __ ---- -- --------Expansion Attic ( ) Garbage Grinder ( )
`4 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers — Cafeteria
a' Other fixtures,..-I,_
Q ------------------------------------------------------------------------------•----------------
W Design FloiV................. t _-gallons per person per day. Total daily flow.-- -. ---gallons.
PSeptic Tank—Liquid eahacity------- Length---------------- Width----------. ._._ Diameter......... .----- Depth _.._... .
xDisposal Trench—No _-___-- -- Width of Ae5h � ,tal leaching area------------- ------sq. ft.
Seepage Pit No Diamete ..__.__ Q'Total leaching area
------ 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-..-----_-:------.------
t14 Test Pit No. 2................minutes per inch pepth of,'Test Pit-------------------- Depth to ground water------------------------
O
------- --- ---- -
Description of Soil R------------------------------------------------------------------------------------------
x
U ......................................=----------------------=..........................................................
W
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 n to place the system in
operation until a Certificate of Compliance has issued b t e bo of he
Siened. .... ..... . --- ---- -- .--
D a/e ,
Application Approved BY--=- -• -•..._ � r '
Da
,,..
Application Disapproved for the following reasons: ...................... ......... .........4Z..........................................................
-------------•--------------••--••--•-----•----------------------•----_._---•--------••---•-•-----------------------------------•--=--------------------------•----•--------------------•---•-----------
Date
PermitNo......................................................... Issued--------------------------- ............................
Date
THE-,COMMONWEALTH OF MASSACHUSETTS
t ,
'~ BOARD OF HEALTH '
.... .. -. .........OF.........: ...: , � ►.: '
rrtifirate of TompItttng.
T IS IS TO CERTIF at the Individual Sewage -Disposal"Sstem constructed ( or Repaired ( )
.. ---- --
------------
Installer .
oe
at ...I ---------
---
has been installed in accordance with the provisions of Article XI of The State Sanitary o �descrjbed in the
application,for Disposal Works Construction Permit No.._---__*---------7! ?---_.-__- dated..../Q _.7/7,:�.._......
THE ISSUANCE OF THIS CERTIFICATE, SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. '
DATE---- -- �J..c�. ---------- Inspector -C l
'•; THE COMMONWEALTH OF MASSACHUSETTS
�µ BOARD OF,HEALTH
.�--
OF
No. F ,rEE... 1....•.....
Dinpo I Workii Ql>a union Vamit
Permission •s granted-- -- -,r i -4Z?. -' ...
at
to Con_ , uct (+Pair ( an Indivi Sew, e Di oral s
r
stre
as shown on the application for Disposah Works Construction Per t o _ K-:- --- .-
....... -•-•----- - ..........
-
DATE.........................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS +
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