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Agreement:No......./LV.... 3()CY - OL4�0 FimE; .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair (=anlndividual Sewage Disposal
System at:
Loc ion�,4ddress or Lot No.
Address
Type of Buildi
Z Other Distribution box ( ) Dosing tank ( )
, �
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XIof the State Sanitary Code— The undersigned further agrees not m place the system in
operation until u Certificate of Compliance has been issued by
Signed.- --_ -_'
. u,�
/�po�u�ou By---------------------------------- - � --_-_------.----
Application Disapproved Date
�rthe reasons:—.-_---_---'-'�................................................................................
.......................................................................................................................................
Date
PermitNo Issued........................................................
-----------------------------------------------------''--''—'''--'---------'—''''----''----------~
j No..............
F�rc.... :... :..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....OF...........
�`�:. w ',"
Apphration for Uiiipoiia1 Works Tomitrurtinn Vierntit
Application'is hereby made for a Permit to Construct ( ) or Repair ( n .Individual Sewage Disposal
System at
a x s
.......... 1...........'vf '.x. _F t.�{__'�. .::" ....--. l'r !�": 4P '^'`"(r'/.'�' .......................................
.. ---------- -- -----------------------------
------•--___..
Location-Address _ {i { or Lot No
J
�T.
jn,�JjJOwnerj Address
J.]. �:G -,f L I- ------------ ----------------------------------•------.-----_----------------_-.----.---_-----------_---------_
Installer Address
dType of Buildi Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—.-Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ........................•--------•-----
W Design Flow............................................gallons per person per day.' Total daily flow.._...__......______..____._..._...__.____._gallons.
WSeptic Tank—Liquid capacity '._gallons Length................ Width---------------- Diameter_.._...-________ Depth----------------
x Disposal 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----------------------------------------
Test Pit No. I................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........................
P4 ----------------------------------------------------------•--------•••--•-•--••-------------•-------.........................................................
0 Description of Soil.............................;------------------------------------------------------------------------------------------------------------------------------------------
x
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 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.
Signed ---- a- a !' ti
.q,
/ a✓ Date
e'
Application Approved BY *- � ?` - f `� ------------ - -- --- -----------
Date
Application Disapproved for the following reasons_________________________________
-•---------------------------------------•--------------------------------------.......................................................................................................................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF.MASSACHUSETTS
BOARD OF HEALTH
C.rrtifiratrr of Tomplittnrr
THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructed ( ) or Repaired
t
�>
s Installer
at. r_. - - ----------------------•-----•---------
has been installed in accordance with the provision of Article XII,/of The State Sanitary Code,as described in the,
application for Disposal Works Construction Permit No..........4�'.y................. dated----- ` _ '_ -_ _ ---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WALL FUNCTION SATISFACTORY.
DATE . � ' _...-----•-•-=-•-•---- Inspector-------�4�--------------•-----------------------------...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF. ."`.a''�.`�-* ''..r..i -k--�" da r4:..................
_41
No....-�" ....--- 1.. FEE.---- ............
:41-sp otia1.rWorks C�nnitrurtion rimmit
Permission is hereby granted........... .............................................
to Construct ( ) or Repair,(?, an Individual Sewage Disposal System k
at No. . 1x s- r �_ ----
_ ..____..'_.],,._.�__.. .,•. .._.} ____�'P ------------------------.__�. 5�.. '^ .... ! h ___________--_-____-----•-------_-
t
` i - Set ! i .• fy
as shown on the application for Disposal Works Construction Permit No.--------------------- Dated_�_�,-r'__,r.._=-'_��:_:_.�-__........
__-0�,-". ✓_i / ,I-.- -a:�-,;`r,f'G::..^""-''{/t.a,._"�----- .........................
A
Board of Health
DATE--•---"3.----------- ---------------------•-----------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS