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THE COMMONWEALTH OF MASSACHUSETTS
ROAD® OF HEALTH
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( � XpVftra$iun for Dhipsal Workii (f.uutitrurtion Vrrmft
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Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
Location-Address or Lot No.
---•---•--fh4_j(Y1f?5 -------------••---•-••-••---•-
a Own&.,., �/ G Address E J ��/v
'd���r1 l�aJ--------------- ---
Installer Address
U Type of Building Size feet
�-. Dwelling—No. of Bedrooms----- _................................Expansion Attic ( ) Garbage Grinder ( )
P.,
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures •-•------------•-••-••-••----•-••----•--•-•----•••••---•-------------•---•-••----•-._...-••-••••••••---•••••••-•-- ----------------------------------
w Design Flow___________J____ ___________________gallons per person per day. Total daily flow____________3_0 ____________________gallons.
WSeptic Tank—Liquid capacity._�D6q. allons Length---------------- Width-____---___-___ Diameter---------------- Depth__-__________---
x Disposal Trench—No______ ____ _____ W th.................... Total Length.................... Total leaching area____________-_______sq. ft.
Seepage Pit No---/Q-01_......Diameter____________________ Depth below inlet.................... 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------------------------
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___________________._--
P4 ..--•-•------••--•--•-------•--•-•-••-•-•-•••---••-•-•••--------•----•-•-•---•-••---•••-----•-••-••..........................................................
0 Description of Soil................................ -------------------••----------------------------------------------------------------------------------------•------------------------
U -------------------------------- ---------------sue��--------/�--.`'r-.'--------------------------------
w
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V 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 aI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue by the board of health.
rSigned..? - .......I -----------Da.t.e..............
. Application Approved By------ _.'-- --------.---------------------------------------------------------------------- ------------------ at --------------
Date
Application Disapproved for ie following reasons--------------------------------------------------------------------------------------••----•-•-••---•-•---------
�
...._------••-•-• •--G • •-•---•---••-•--•-••---•••-••_...-
•••----•--•-••••----•-•-- -----
Date�� � ��------ ----------------
Permit No...... .................................. Issued.--
Date
---- - -- ---- --- ----------------------- - ---- -/�
No..-- eV F�s...... 1....... :..t�......
•--- ,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................OF..........
,r' -
Appliration for Dispaiial Works Tonstrurtiou Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
s :.
............ > "' �A_ :.1._..r�."r�..._....1 l.../�.--7....!?:G.... -I_ !f-----'=--..: ............................................
r e" r ••
Location-'Address or Lot No.
................' ___ .......... ............................... ............_....._._............................................................................
+1 Owner- Address
W .....................•'` _j................-...... o c'`.Z-CYi#:,tt s� /9 d�#./i Er,. s_:'±._.._... a A td": -------
Pa
�/ rg ' Installer Address
Q Type of Building Size Lot------- ...Sq. feet
Dwelling—No. of Bedrooms........1.3--------------------------------Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Building _______________ No. of persons-___--..-___-__-_________-__ Showers — Cafeteria
Otherfixtures ......................................................--------------•---------.
W
Design Flow-_______---__:_....r_....................gallons per person per day. Total daily flow.............?__/-!'...._.._____._______gallons.
W Septic Tank—Liquid capacity----£ .r gallons Length................ Width................ Diameter-_____-______-_ Depth----------------
xDisposal Trench--No................•.._. Width-----_-------------- Total Length-----------_------ Total leaching area--------------------sq. ft.
� , K;;
Seepage Pit No.___,! ;f;! ?. Diameter.................... Depth below inlet.................... 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____-_______________-__.
ff14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-__.--_______________-_.
Ix ••-••--•---••---•-•--------------•--•-----•-••-•---••-•----•-•------•---•--•••-•----•-•--•-•--.-----.........................................................
0 Description of Soil.........................................................................................................................................................................
cx ---------------------------------------------------- ° J � f �` '
�.� ---------------------------
--------------------------------------------------------------------------------------•-•-•----•---------------------.....----------------- ------------ ------------------------------------•---------
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 issued by the board of health.
� v
Signed---; ••-- rw;,e , - � �-
�, ���" Date
Application Approved By------ 1....... -----------------------
Date
Application Disapproved for the following reasons:............................................................ ------------------------------•-•---..............
........................................................................................-...........................................................----------------------_..........................
Date
Permit No.-......l F t'` --•-•--•-•-•--------------•------ Issued............4_: -•----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
{
...:...; ................OF......:�''V r, w T "t..
Aaer#if iratr of f91iutliftatt ae
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (,K or Repaired ( )
Installer /
" e !J
has 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........_s?.�- _ ................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM VLL FU TION SATISFACTORY.
DATE
. ........................... Inspector................................- --`
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF-14EALTH
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NO _/f' ...........t •„:............OF... FEE r/
i q. ._.....-
•_- .._ __ ..�:. .. •d .....---•_......_ ....
�i��ua�ol urk.� C�un�trttr�i�r� �rotli
Permission is hereby granted , , ---------- =� + W .........
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
r
._� ,-u
w z•
Street
as shown on the application for Disposal Works Construction Permit No-----_^_.of€:... Dated........ _.:y r`. ... . .........
of Healt
DATE f'�' `-rl
t, Board
FORM 1255 HOBBS & WARREN. -INC., PUBLISHERS