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THE COMMONWEALTH OF MASSACHUSETTS
_B 0, A R Dff 7f
_._.. . .... OF.....
, pplirFation -for Mtivoii al Vorkii Towitrurtion Prruift
Application is hereby made for a Permit to Construct (4) or epair ( ) an Individual Sewage Disposal
System at: a
Location-Add or Lot No.
Owne •-----•.....................................Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedroo . _-.--_--- -_-----.--Expansion Attic ( ) Garbage Grinder ( )
p`1 Other Dwelling
of Building' .__ 6P.Yki44_-__. No. of persons--------� ®_-------- Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------------------------------
W
Design Flow..................... .__.__.. allons per person per day. Total daily flow--_--__-__:-- ___.______...__.._gallons.
Septic Tank Liquid capacity ______ allons Length................ Width_.___._....._.. Di meter...___..-_._.__ Depth.__..-.-.._.._-
x Disposal Trench—No..................... Width........{{,,____-- _ __ 1 nelef
al leaching area.__...__._.._._.__sq. it.
Seepage Pit No.-___1..........._ iameter/ (0_ .. e e ow ........__.. otal leaching t rea_._..____.._..__sq. ft.
z Other Distribution box ( Dosing tank ( ) � /�= 7 G �.,
`" Results Performed b ._-_--__-_ /
Percolation Test Res is Y ---------------------------------------------------------------- Date--------...--/-----,1-_----- ..
a
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------------------------
-
G4 ------------------------------------------ -- --------------------------------- ----- ---------------- ------.--------------------------------
Description of Soil. � -
x
W --------------------------------------- -------------------------------------- -------------------------------------------------------------------------------------------------------------------------
UNature 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 Cod e undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ii sued he b rd of health.
igned...... --• -- - ----------•-
Application Approved By......... --•--
Application Disapproved for the following reasons----------------------------------•----- -•-----•----------------------•-•--••••••-••----•--•-•-••-----•---....
-----------------------------------------------------------------------------------•-••---
Date
PermitNo.......................................................... Issued..... f ��-- --.
"�'— ------------------------------- ate-------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL
OF...... .... ..... -- --- ... ------------
AppIira#inn fnr IN� ulitt1 arks T nns#rnr#ian Pumil
Application is.he made for a Permit to Construct (�or epair !( } an Individual Sewage Disposal
System at: {
...................... - ---- - •--•-• -- - -------- -----------------------------------------
Location-Addr or Lot No.
.
......................................
Owner r Address
Installer "—>,, Address `
Q Type of Building Size Lot.............................Sq. feet
U Dwelling No. of Bedroom -- -------------- __--__. _------___Expansion Atti ( ) Garbage Grinder ( )
`-1 Other v e of Buildin ._. _
a yp g� .__.��"�'>FI!1�.�:._. No. of persony+__._.:�....:..:..... Showers ( ) — Cafeteria ( )
Other fixtures = -------------
Design Flow... ............:........ allons per person per day. Total daily flow------------ '. gallons.
W Septic Tank-1-Liquid capacity_/) allons Length---------------- Width................Wo't-al1leaching
eter................ Depth.._._..__.._....
x Disposal Trench o. ....._..__. Widtli________ _____ �115
. T eaching area--------------------sq. ft.
Seepage Pit No ... ._. ._ iameter_ .. .+_ '_`_` area------------ -----sq. ft.
. r ,�✓��
z Other Distribution box,( Dosing tank ( ) !�-C ..' 1 f r��/7
Percolation Test Results Performed.by........... ------------------------------- = Date
a 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__._--__-___-_ .-__-.._.
---------------------------------
,' O Description of Soil-------- ----------------------------------P =
x
U
fW ........................-------------------------- - ---- ----=- ----- --- - •----- ------•-•----------•--- - ------•--••--••-------------_-._..-------•--•-----
UNature 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 e undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu d e b rd gf health.
gned f --•-- ---- .......
# j ` t�
•Application Approved BY------------ -- - �<---- -- - - -= - --�:�.- ---�(-�-t--�-------�--`�
,. to
r Application Disapproved for the following reasons:.......:.......... .
.................•-•--•'-------- --------------•- •--•-------• . --•- -•------------•-•-•-------------
' E ,.D to
PermitNo..............................................`-.......... Issued....... ........ ..:......
�, f Dat
/
ti
I' THE-'COMMONWEALTH OF 'MASSACHUSETTS
BOARD O) HEALTH t
t
Y
err#t�ir�#.r of f�nnt�li�tnrle
i THI IS TO RTI , That the Irdiv al Se ge s S;� tem structed ( or Re aired ( )
<.
l by ... ' . 4...«'S+7! !tM/ --1
I staller I J
t
at...."'................... ` "`"
has been, installed i acco., ance with the.provi ion of Article XI of The State Sanitary Code s des abed ,in the.
application for Dis osal;.Works Construction Permit No.............: 4� _ ._ dated._.._.._ 1 :_
PP P l- 7-----
THE ISSUANCE OF THIS CERT3101CATE SHALL NOT BE CONSTRUED AS A R NTEE THAT THE
i SYSTEM WILL F NCTI N SATIS AtCYORY.
DATE.........., 1 - ---------•--- ---- --------------- Inspector----• --•- .--- =-- •---•--- ........................... ...
t' THE(.COMMONWEALTH OF, MASSACHUSETTS
�� -- BOARD F 'REACT
t_ No.----- FEE........................ -
Dtnpniitt1 rkti TTIn nr#ila tr
Permission s Web granted-!------------- -- -- ---- - -_. ........ ....................... -- ------------_..
�'-- to Construct ( pair (• ) tvidu age D• stem s` t
atNo.--•................... --- -•-- --•-... . ---+_-------- :-- ---- -- -
`'._ as shown on the a lication for Disposal Works Construction P `tieetNo.____
*
_
. soar of Health
DATE -----------=-----------------------------
FORM 1255 HOBBS. & WARREN. INC.. PUBLISHERS -
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