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THE CALTH OF TS
OAR® O HEALTH
'C!J � _
J C`' �Appliration for Disposal Works Tonstrurtton Vrrtnit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
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._.__.__....ro ........................................................�_..... ...-.... ..._......_....______.___..__......_......___.._..._____.____ __.__....._._.__..........__.___..
Location-Address or Lot No.
...---�......-•�� �� � ..............................................
..••-------............................... --••-------------•---•--.......................
Owner
Address
----------------
Installer Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther Other Type of Building � "- ''`�'^ No. of persons.-__-__wL•______________ Showers ( ) — Cafeteria fixtures ......................................................----
W Design Flow..................
........................gallons per person per day. Total daily flow......__._.boo_-_•__-----------------gallons.
WSeptic Tank 4--Liquid capacity!o0!?__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----�_Q_'--.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--_...----_•_______._---
rs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_____------_---____---.
--•-------------------------------------------•---........................................................................... -- ----•.• ......--••.•.
O Description of So' ���'� G v� . - - __-_ A `
00
-----t------- ---
; 70
W - -- - -- ------ ----- -----••••• -•••- --- ._..:�e
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 issue y the ealth.
Signed---- --•-••-• --•. •.._. .
--------------------- --------------------------------
Application Approved B Date
`T� 73— �.d
Application Disapproved for the following re¢sons:_! ..................l P_•�-� __-<%-- --- _...._.
Date
PermitNo......................................................... Issued---..i / '...
Date
f
No. a_.. ...._.... Fic ..................
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
... ....... ...-.....OF..... ......� ..
Appliration for Disposal Works Tonstrortion Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
- .---- ---- - --•--------
Location-Address or Lot No.
Owner Address
M Installer Address
Q Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( )
ersons-___________�___________ Showers — Cafeteria p-, Other-!!?Type of Building No. of persons ( ) ( )
a'' Other fixtures ___________________________
W Design F ..............................._ ________.___..._____gallons per person per day. Total daily flow........... ___________________-..__gallons.
WSeptic Tank Liquid capacity/_a®�gallons Length---------------- Width---------------- Diameter........-------- Depth----------------
x Disposal Trench—No.____________________ Width.................... Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No------- Diameter!�!F!F�'bepth below inlet.................... Total leaching area-----:!�a_-_Z_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------------------------
tTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................
.-
P4 -------•--•-----------------------•-•-•---••••--------•------------•----•-••---•-----•-----------•..........................................................
ODescription of Soil...... 55-- � s!-�....................................................--------------------------------------------------------
x
U ---•--------•-----------•---•---•-----•••••-•------------•---------•------•----------•-------••---•-••--•----------•--------------••----•--•-------------•---------•-•-----•---•••••-------------------
W
---------------------- ----------------------------------•----•••-•-•--•••-•-------•-•---------------------------------------------------------------------------------------------------------------
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.
Signed
Date
------------------
Application A roved B `_.
PP Y o�' �' ate
Application Disapproved for the following reasons:--•"------•----•--------•••-----•--•------•--•-•--- -••--------------------------••----•---•--•••-----------•--
-••----•-----•-•••----------------------------------•-------•--•---•--•---•---------------.._..__._...••.--------------------------•-••-----•-------•-----•---------------•----•-----•-•-------------•--
Date
PermitNo......................................................... Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
4
.................OF.... + .....................
Cnrrtif iratr of (gootplittorr
THI S TO CER 'I)FY, Tha the Individual Sewage Disposal System constructed teor Repaired7y ( )
" w Installer �3
at
has been installed in accordance with t�ie_pprovisions of Article�I of The State anitary Code as escribe i h
S - described me
application for Disposal Works Construction Permit No......................................... dated _ ......................_' _,,�'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED , A GUA A TEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................................------------------------------------- Inspector.............................................................=....................
=
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-, ,
No.........:.............. FEE } --••-
'Bisp sal P
orks ustru tion rrinit
Permissi is hereby ranted
4 Y g .r r
to Contest c ( ) orb n Indi ilewa e Disposal System
..
St'eet
as shown on the application for Disposal Works Construction Permit No Date `/``73..............
:;
M
�� r't ,.•% o rd'�b��alliG ;
DATE --------------------------------------• ,r'`
0
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .
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ry .fir - 1✓Esr , .'s ,- .
9
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a7wLey„r
' c7/aurlc/• 5/G/E'.'S �.
C
�j5 ALL SURFACE WATER MUST BE SELF CON- i
T I A NED.
OtA
41
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