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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HE
L
................0F......1-:.?a..... ......... ..................
Appliration for Disposal Marks Tonstrnr#ion Vamit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
L ti Address or Lot No.
���
_- -------------- -�O Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms-------------
3__._:_.___.__.____...__....Expansion Attic (�"� Garbage Grinder (�'e)
aOther—Type of Building ............................ No. of persons.---.._.______________-_-___ Showers ( ) — Cafeteria ( )
Otherfixtures ......................................................-------------•.....----------------------------•----•------------------•-----------------------
W Design Flow..........•.......................��gallons per person per ay. Total daily flow............................................gallons.
P4 Septic Tank—Liquid capacity/_.....gallons Length......•---_-__-. Width-----6........ Diameter................ Depth__-______-___---
Dis osal Trench—No..................... Wi h......_.__ _-__. To 1 Le h___ ......®....._. Total leachin area--------------------sq. ft.
Seepage Pit No.___l_______________ Diameter. ___._ e e ow in e ....__..._.________. Total leaching are to2.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__-___-________-_____-_.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-_____-____-_____..___.
O Description of Soil-------s..fw
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 not to place the system in
operation until a Certificate of Compliance has been issue y the bo of hPPh. J;
on Si ed.. -
Application Approved BY - ------•----- �c --- " �
�. ._..
Application Disapproved for the following reasons-------------------------------------------------- -------------------------------------------ate--------.._..
..---------••-•--•-----------------------------------------------------------------------=------------------------------------- --------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
22
Fx$.....v.... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® HEA_ T
III ............................OF.........."y�........................-----------------------------------•-----•-----
, pptiration for 43i5posal Workii Tomitrurtiou ramit
Application isjiereby made for a Permit to wC-onnsstruct ( or Repair ( ) an Individual Sewage Disposal
System at:% 41 /1
- ----------------------------- ------ m
- �,�,. Loc i ess Lot No.
---------- ----- -- ----•------ .............. •----------••--•--............................ ......•-••---------••-----
Address
W
Installer Address
Type of Building Size Lot.........:..................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( '` Garbage Grinder (
Other-Type of Building •___________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures _____________
W Design Flow.................................... .. . Mons per person peay. Total day,flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter----- Depth----------------
x Disposal.Trench—No..................... Width.. ... Total Lef gtI ..._._._ . Total leaching area......,��, .sq. ft.
Seepage Pit No_ _________________ Diameter , bei`-ow eihle _._.________.___._._ 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--____--__-____-___.-.__
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -----------------------------------------------------------------...............................................................
DDescription 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 Code— he undersi ned further agrees�ot to-pp��..ce the system in
operation until a Certificate of Compliance has /e amiss he belt L,� 1 s/)
Signed__
Y �
, f ----------------------•--------.-- t .....................
Application Approved By------ r: ..... -----•-'.....e-----140�� g e
Dat
Application Disapproved for the following reasons................................................- --------------------- ......................................
--------------------------------------•------------------------------------------••-••-•.....--------•-•-I-----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
r
THE COMMONWEALTH OF MASSACHUSETTS rJ 42 `':�-2
BOARD OF HEALTH
. 4 : ..............OF.... .., .. +a ........._..
..
Tutif iratr of ITU mpfiattrr
T IS TO ERTIFY, X,6t the It vidual Sewage Disposal System constructed ( ) or Repaired ( )
.�
at• _ --Y m* � s _ Fnstaller �xb , 4 `'j "' � ...
FN -------------------------------------------
has been installed in accordance with the provisions of Article XI oYThe�State Sanitary Code as described in the
application for Disposal Works Construction Permit No...--------------- .. ""..__.. dated______`' �lx'__ __=c•_....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
—
Jr—. `t " �, ............... Inspector G1 = -' ���
DATE.......... •---------- - . ••-•---
----•-----•-
1
a
THE COMMONWEALTH OF MASSACHUSETTS
/�? ;2
BOARD 'OF HEALTH /;;2`
-3.. . OF..........
No......................... FEE-......40
Di-spotia orka Tot g Urtiot Vrrmit
Permission i here ranted-_-__ �.•._
A y g n ,`' "°°°`r y a t °' -------- ...........................
rue jor Repair ( ) an'=Indtvidual Sewag fDtspos 1 System �
to Const
Z Street �/N Y
as shown on the application for Disposal Works Construction it No Dated___. s r j1
r�y ��fpj¢, �..............
yip ...........................
Board of Health4
DATE.........................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS