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No....... 1_.a._._.... FRS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF, HEALTH
OF.............
Applirati.an f aT Dhipasal Morkii Ton5traartion Vrrufit
Application is,,he-eby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
�L -Address - ------•-.-•------_•-----•-•---o,at, n, or Lot No.
y•t ' Owner ddres s
/ C (
CA
r_ Installer Address
d Type of Building '" Size Lot_LG q-$_-0_______-.___Sq. feet
U Dwelling—No of Bedrooms..-----------------------------------Expansion Attic ( ) Garbage Grinder ( )
..Other—Type of Building ---------------------------- No. .of persons---------------------------- Showers ( ) — Cafeteria ( )
W Other'fixtures ---------- -------------------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow....................................--------gallons. .
9 Septic 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 ( )
Percolation Test Results Performed by--------------------------------------•------------------- Date-•-•---•---------------•---------.-----
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water.._____.--.-._--.-.._..
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit-----------_________ Depth to ground wate ------------------------
-
a ----------------(----- i, -
W
.............0D --
Description o o ---- - --- --
_ _____ __ __ __._____.--___-______-__-_._--.___-___-_-_-.__-_________________ _
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 b issued he boo rd of health.
igned-- .---- •--••-=- - ......................
Da4e
Application Approved By ---------- --_..... �-- -...� �p� E 71
;{
D to
Application Disapproved for the following reasons:-------------------------------------- ----------------------•-••--•--•----------•--••__..__.----•- -•---------
-------------•--•-•-----•-•-•--------....-------•---•---------•-•---•--•-•----------•--------•--------.....-•--•---••-----•••--------....••----•-------- •-----•---•-----•----------•--••----••---------
D u
PermitNo......................................................... Issued........ .7.
Date
THE COMMONWEALTH OF MASSACHUSETTS
EOARD O HEALT..H
........OF..... ..... . ... .. - -- -- ------- •.
ApV ra intt -for Bbtip oal Works Towitrurtion Vrrmit
Application is hereby made for a Permit to Construct:( ) or Repair ( ) an Individual Sewage Disposal
System at:
l Y� r_t1.• C• c�,,�fit' �r C".:_ ............ )-----. . -•---------------------------------------
Locati Address or.Lot No.
1t"jr.-----�.....rt t rC_ _f! rt - 's!:_ f"4?_> _j_.!v/_cc�s�.Y.
AOwne � /"� �y f Address
:.
staller Address
d Type
o Building
of Bed Size Lot/!X, .............Sq. feet
Dwelling— rooms____________________________________Expansion Attic ( ) _ Garbage Grinder ( )
PA Other,:''Type of Building ___________________________ No. of persons............................ Showers O — Cafeteria ( )
tpgOther 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.
3 Seepage Pit No--------------------- Diameter.................... Depth below`'Inlet......:........... Total leaching area-________-_____.sq. ft-
Z Other Distribution box ( .:) . 'Dosing tank
Percolation Test Results Performed by..____- . "'
-------- - Date------------------------ ---------- -
a .,..� �.
Test Plt Vo 1 minutes per inch Depth of 1 esttx pepth to ground water------------------------
(� st Prt No 2 __:�.'ri`_minutes per inch Depth of,Test Pit __________________ Deptl�ao,ground wat ._-...._:____________-_-
Descri Description of Soil___-* ""' -___
•,.
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' issued the b,and of health.
igned _.
iFte.APPlicatiori Approved BY - "'t'� = '�
=.
Application Disapproved for the following reasons_......._............_..........______ ________________________::__________._._____._________....................
--------------------------•-•-•-•---•----•-••-•------•--•------•-..----------------------------------------
Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0, HEA)/LT�H\
}.
..... ..................................\�
(grrf firatr of Tlintjtha rr
THy IS TO T tFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
L
........ --•--•-----------•--•�1�n ------..-•-- -- • ----------------•-----------•--••-••......•-------•------•-•-
at
has been installed in accordance with t e provisions of Article X he State Sanitary Code s descri ed in the
application for Disposal Works Construction Permit No-___•-C__ ____ ________________ dated..-. ��lZ►.�_�17_x,........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST E® AS A GUARANTEE THAT THE
SYSTEM WILL NCTTIIO SATISFACTORY.
DATE _---1--------••-•-----------••-•--•---- Inspector-- :., a...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 91F HEALTH
No._ .v -------- wI FEE__„ .
Permission is hereby granted_ R
to Constr t ) or, r an dividuaI S e D osal System
� ,,
I, Stie � ..:y.,•
as shown on the application:for Disposal Works Construction P o.__ :::. Dated_._7 .. ____-. _-__-
---- ------ -- -
Boa of Health
DATE.--•� V r--- ----------------"--------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -•-