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THE COMMONWEALTH OF MAS CHUSETTS
BOARD F HEALT
_. ... . OF.. ..... .. - - -- ---.............
Appliration -for Biopooal Works Tonotrurtilln Vrrniit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
y
st at• i
Localoa- res or Lot No. ------/
w r, Address
staller Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ----------------------------- No, of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------------------------------------------------- ---------__-------------
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
USeptic Tank—Liquid capacity------------gallons Length---------------- Width.--------------- Diameter_--.--_-._-__ Depth----------------
xDisposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet-------------------- Total leaching area------------------sq. ft. ;
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------------- ...................................................... Date--------------------------- ------------
a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..-.-.-_-.__--__--_-_._.
4_4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to.ground water........._..---.__.-._..
I+ -------------------------------------••-•---•--••------•-----------••-•--------••-----•----••-••-•-•........................................................O Description of Soil--------- ---------------- ...............................................................-•-------......------- ------------------------------------------------------
cU -------------------------
------------------------------------------------------------------........................a.............................----------------------------------------------..-----
---------------- ---------------
- - - - ---- -------- --- -----------------------
U N ure of Repairs or t�rati ns—Answer when app e...'d �� -f o�� 1
• ------ --- -------------------------
Q'
greement
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 b n 'ssued by the board o eal
Si. Date ned . . - 1
Date
Application Approved BY----- . ••-- ;;: "e. e
Application Disapproved for the following reasons:................................. .....
easons:................................. .__.. ..............................•---------•--•--•---
. ._......._....
------------------------•--------------------•-------------------------------------------------------.....
Date
PermitNo........................................................ Issued...................... .................................
Date
- ------------------------------------------------------------- yr
•+
` �.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 0 F... . ......
Appliratiun -fur Uin,puntt1 Workii Tomitrurtiou Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
Syst at:
r1 .�a _ I
/�` L�oYcatio - res or Lot No.
(.-- ...... J _. -..-----•.— r --•--..
W Own Address
staller Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type Of Building ____________________________ No. of persons..-.------------------------ Showers ( ) — Cafeteria ( )
a' Other fixtures -__----_•---•---------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter................ Depth_..------.......
xDisposal Trench—No_____________________ Width........_----------- Total Length------------------.- Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter____________________ Depth below inlet.................... Total leachilg area-___--____________sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY--------- ------------------•-•••--••---- -----------------•-----•-------• Date---------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit..........-......... Depth to ground water.---_-__-___-__-__..___:
fzq Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
9 .....................---.................................................................................................................................
0 Description of Soil------------ ---------------------------------------------------------------------------------------------------------------------------------------- ------------------
x
U ------------------------------------- --------•-------•------------•-----•---•----•-•--•-••••-••-------•-•••------;-------------•------------------------------------------------------------------
-------------------------------- ------------------------------------------------------------------- --
Na ure of Re airs or terati s—Answer when a e.._ --. �. _..____.__ DU _ __ _______________
-----------------------
UP PPS ..._- - -•• ----- - ---•- --
C.-' ' j- : -----------------------------�----------------------------------------
greement
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 b n 'ssued by
the board of h al �l
Si _ned- -_ ` 1's _ / L - q54---- � Q
Date
Application Approved BY c,r_ = ------ -- -----
e Date
Application Disapproved or the following reasons_________________________________ _______.._.-...._._....-.___._.____....__...__.___.________..___.__-...-
PP PP t f 9
-------------------------------------•-------------•----------------._._...----------•-••-----------•----•---------------------...••---•------------------------------------•••-•----------------•------
Date
PermitNo........................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS 4
BOARD O•F HEALTH
........rou)_4.........OF............. ...../•! ........... :..........`......r.:. ...............
QuIertif iratr of QVI'ontpiiatta
THIS IS TO ERT Y, That the Ind' dual Sewage Disposal System constructed ( ) or Repaired
-- -------(-�-�`iJ��
�l nstall rf"F!
I e
has been installed in accordance with the rovisions of A'Ot-1 XI of Th State Sanitary C 1e as describedAn the
application for Disposal Works Construction Permit No._, ._.__ __ _____-._.. dated_�1_..._at� "� _'�_._._-____-_
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------ ----- -le—,
... Inspector_- = = -t
THE COMMONWEALTH OF MASSACHUS
BOARD OF HEALT -
' , d"'�'�?'.!'`.........OF....... ............ • "'
No......................... FEE-J_._-1................
BinponFti Workii T nstrurtion rrrnt .t
Permission is hereby grante -------- -- ----------------•--------------. . .--- ---... .........---•---------- ----------------------
to Constr •t ( ) or Repair`( a Individual Sewage ➢i`sposah'System
Street r,"_�• ;�
as shown on the application for Disposal Works Construction Permit No. �'� ted S-��" --__________________---____-_
• Board of Health
DATE -----------------------------------------------------•-•-•• �b
FORM 1255 HOBBS & WARREN.. INC., PUBLISHERS