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THE COMMONWEALTH ormAssxoeussrTs
BOARDHEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
41
or Lot No.
_...... ____--'---_----___-_-__'.---_-_---___--
' InstallerAddress
Type of Building Size Lot...........................'Sg' feet
DweIlinV,--Z`No. of Bedrooms-----�..��----------------------------Expansion Attic Garbage Grinder / )
Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) -- Cafeteria
~� (]tbor 6x ------------------------------------------------------------------------- ......................................................................
Design Flow ---�---�l' _^� per person per day. Totaldaily flow----�^�*����_�...-.caDouu.
Srp6oTank�-Lo ' AuDnos Length................ Width---------------- Diameter---------------- Depth------
uispoou Trcuou ---- YV Iota eucbmgaren----_--'sq. f .
Seeage Pt ry .-_-. u -t���-� o��uo ���� nlet---'-__-' Iota badiugaccx------aq b.
Z Other Distribution box ( \ Dosing tank ( ) �
~~ Percolation Test Results Performed by.......................................................................... Date--..-------'._--'
�
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
riq Test Pit No 2................minutes per inch Depth of Test Pit.................... Depth toground water--------------_-.-
04 --------------------------------------------
-'_-_-__-_-_----------'------_--------.-----__-
~~ Doxcr�tix/ u[ S�L-----_---_-----_--------------------------.----------'--------'-__---.
.......................................`.......`...`......'..................................`...........`............................`......................---------------------------------------'-
__---.----------.-_.-_-_'----_--'_-_----._''-'-----__.----'------__----.---'__-_-
L) . Nature of Repairs or Alterations--Answer when -------------------------------------------___---------_--
___-'''''-.-_'-_----___------_-'_--____---.--------_----.-.-_----'-_----_-- �
� '`"'-_-_-.
� The undersigned agrees to install thexforedescribed Individual Sewage Disposal System inaccordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not mplace the system in �
operation until a Certificate of Compliance has been is d by the arrf health1.7�2
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' ���������������J-l7-----'----' -- ..-'--......
Application Approved Dv-' --_---.---'_---..
, Date
Application Disapproved for the following roosonx:-.----. ..-----_---_--------------_--`-_----_-----'
--------------------------'-----------------------'------'------------------'-'------------
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Permit No............................ Z. ------------------------
- ''' ''' '-' ' '' '-'' '' '- -----------------------------------
No. - ; Fxs... .................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD , F HEALTH
r
Apphration for Riipniia1 Works Tontitrnrtinn lbrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Dsal
System at:
¢; - - ,- •----Ael ==�'' .. ..' -—•- -----•----•--••----•--------.-------
I.ocation-Address or,Lot No.
•--- . . r/ -----............................... ...---••-•--------------••---...--•--•-----••----....--------------------------------------------
W f , Owner Address
......... _ _�r1/'La.•_ „_..__.P .. 'Gt?'.6L:-: ____________________ _______________________________________________________________________
Installer Address
Q Type of Building Size Lot.............................Sq. feet
DwellinV.;,�No. of Bedrooms____-� ""'r_______________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fixtur s --------------••------•••--
Design Flow_ ...................e.:__...............gallons per person per day. Total daily flow............. �"°`:"'�2_._ -_.`__---gallons.
W -
WSeptic Tank—Liquid capacity/ - allons Length---------------- Width---------------- Diameter---------------- Depth______________--
x Disposal Trench—No_____________________ Width........... T tal L gtl�__-.__._________.__. Total leaching area--------------------sq. ft.
Seepage Pit No.____ ___ Diameter _ a____'"D nlet________ _________ Total leaching area------------------sq. ft.
3 / �v P
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date-------------------:••••---••••-•••----
a
Test Pit No. I................minutes per inch Depth of Test Pit____________________ Depth to ground water------------------------
r.Tq Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water_______________________-
---•................•-•-----•-------•---------------•--------------------------------••-----•-•-•--•.........................................................
0 Description of Soil-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U. -••-••••-••-•••••••---•-•--•-•------------•------------•-----------•------•------••-------------•--•--•--••-••-•-•--------•-•--•----••••---•••--••••-•----------------------•-------••-•••-•••----•----
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--------------------------------------•----•--•-----------------------------------------------------------------------------------------------------.-..•-..------------------------------------------.
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 issI&A by the board-of health. �i
P1 k/ t r`' .
Si ed_ __t It = f. c f` ---
Application Approved B e_ .. ce __-_____
Y----- = _ a:
+' Date
Application Disapproved for the following reasons:------ -=---•--•----------------------•-•-------------------------------•••--•-•-=-----------
--------------------•----••.............................................................-...............................................................................................................
Date----•--
Permit No......................................................... Issued.-- j .e•---------
s Da{'e-- -
THE COMMONWEALTH OF MASSACHUSETTS
' BOARD OF HEALTH
Tatifiratr of Tomp.lianrr
THIS IS TO.-CERTIFY That the Individual Sewage Disposal System constructed ( }` or Repaired ( )
bye? �" P. � � � -----------------------------•-------._.....__
------------- ------
t d Installerje
at............ "4 -- ------- � � ,>' '�=------ZW-e ........... �� �4. --------------------------------------------
has r
been installed in accordance with the provisions of Article XI of the State Sanitary Code as described in the
application for Disposal Works Construction Permit No...... _____________________ dated----- :...................
.
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 HEALTH ",
) r •.' n'.g .st-.R'Ny...........OF.... .- -rll.�I y�- � r�-if: ..h.,�: .................. c
Not- .._..------ „d FEE : .. .
�i��n��a1 3�nrk,� Cn�rn��rnr�i�an l�rntt
Permission is hereby granted_._._ _4 �IA ?_ ,-j__. c= -f'_a: .�~ ______________•...................
---
to Construct (4 or Re air ( )¢an Individual Sewage Disposal System r
33�P
._-` +------X: ._ r-i
Street fi j_
as shown on the application for Disposal Works Construction Pern-ait Now - ��___.._. Dated____ /a - ': ..............
------------ --••------•--•----------•-••-----------------••... ............................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBEISHERS =
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