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No......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® Of HEALTH
Appliration -for Disposal Workii Tonstrnrttnn Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at:,
!)
Imeatd .Addres o`�_Lot No.
ner Address
Installer Address
QType of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedro -----Expansion Attic ( ) Garbage Grinder ( )Other Type of Buildin - k4/-e..,No. of persons------ ___ Showers ( ) — Cafeteria ( )
a' O her fixtures ................ .
----------------------------_ -------------- .: ---••••••-----•---
W
Design Flow- -------------------- ........_. Ilons per person per day. Total daily flow_______-__-----.�: .__._..._.._..gallons.
WSeptic Tat uid capactt . _ ._ .__ allons Length................ Width.........-...._. Diameter................ Depth.____._-.....
x Disposal -No..................... Width.................... Total Length------------------.. Total leaching area ft.
ft.
Seepag .o.____-__-•---_------- Diameter.................... Depth below inlet.. ................. Total lea ittg area------------------sq. ft.
Other Distribution box ( ) Dosing tan
z ) --DD /9-
Percolation Test Results Performed by-•--"'---- .... � Date-- ----------------------_--
a
Test Pit No. I................mtnutes 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--.__._._-_.___..___-.
--••------------------------••----•------------------------------------•---------------•--•-----•------•-----------------------------------------•----------
0 Description of Soil-------------------- =--------- ....--
-
W ------------------------------------------------------------I- ---- -----------------------------------------------------------------------------------------------------------------------------------
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—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ed by the boar Uhhe th.
ned. •. • ---•• ----
.g Da
Application Approved By-------------
f • ----•-•----0- g `ram-------
Date
Application Disapproved for the following reasons:----------------------------------------- -- -----------------------------------------------------•--_----------
---•-----•-------•-----------------------••••---•--•---------............•-••-----••--------•--•----•--•..............---•-•----•-••. ---- ------------- ----------------------------------
Date
PermitNo.--•-••-••---••-••--•---•-•------•--•--•-••--•----•---•• Issued .............
D e
No..-- :L�---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
""Z•, �t 0F...... . er,.«G•L°-c-�^'~'t ,-........* "' ................
ApphrFation -for Dippoiial orko Tomitraution Permit
Application is hereby made Pr a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at
- ___ ::...: ___ . -__- ... ._. __
Host n_Addre ft Lot
No
w� •
wner ddress
y
a .___._.... ------- - - --...................... ----------------------------
Installer Address
UType of Building Size Lot............................Sq. feet
.-I Dwelli g—No. of Bedro ___________________________________________Expansi Attic ( ) Garbage Grinder-( )
Other Type of Buildin _ _ . ,__*No. of persons __________________ Showers ( ) — Cafeteria ( )
Other fixtures =-------•--- - -------- . .......---
W Design Flow._ ______________ __ __ Mons per person per day. Total daily flow.................. .- .............gallons.
WSeptic Tctf uid capacit Mons Length-------_------- Width-------- ....... Diameter---------------- Del) 1 ----------------
Ix Disposal 'No_ _____________________Width--------------------- Total Length...._ '______._._ otal leaching areal__----------__.__sq. ft.
Seepage. -_,.N.No_____________________ Diameter.................... Depth below inlet
Total lea ling trea_- sd. it.
z Other Distribution box ( ) Dosing tan )
a .Percolation Test Results Performed by-__'"""'----- .. . Date__ ______
Test Pit No. 1................minutes per inch Depth of "lest Pit................ -Ipth to ground water--_-_-__-__--__-__-__-_.
G14 Test Pit No. 2..._............minutes per inch, Depth_of Test Pit............_....... Depth to-ground water------------------------
Ix ----------••-----------------•--••••---------------•-----•--•------------------__--------------------------------------------------------------•-----•---
O Description of Soil____________________ (___ _ __
x �"�"
V ---------•----------------------------------------- - +�' ! -
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—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been Lmvged b the board Udhe h
Signed - - ................. ••. ................ . - -- - ---- •---_. Ir�_.__
f ✓ -----
Dale
AApplication Approved By ----- ----
j Date
Application Disapproved for the following reasons: •-------•--•-----------•--•--- =------------- --------------------------------------------
Date
PermitNo......................................................... Issued----_--------------- ................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OA HEALTH
........... ........OF..........4401 6:44-400lt-1-2...................................................
(Srrtifiratr of Tompti-a rr ✓,,�
THIS IS TO CE IFY, That t Indivi Sewage Dis osal System constructed ( ) or Repaired ( )
.� In r
at....... ;'r'f / ,.�.. d -----..... _..___..._.................................... _
has been installed in accordance with the provisions of Article XI of he 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 Q1r HEALTH
No. ! ....... ........... _......OF........ ----- FEE
---._...... 'I
- %tivo,s luorkii Cno �txaa t �>�raatt
Permission is hereby granted• ------------------------------------------------------------------------------•--••-------_...
to Cons ru ( ) o Regpair ) a Individ>,Ial Se e Dispotyl System
at ....... --- --- ------""-" "------------------------- --------- - ----------- ---------------
eet
as shown on the application for Disposal Works Construction rm* ____ Dated__________________________________________
�"
------ ---------- ------------ ----- -�— ....---------
-Board of alth
DATE....flll'5�'1-73--------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS