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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ .........................OF..........................
Fim...r�1.S e�
ApplirFation for Disposal Warks Tom3trurtion Prrutit
Application is hereby made for a Permit to Construct V,-'�or Repair ( ) an Individual Sewage Disposal
em at: _
..... ........... .4 �.--•---......---..._...---.......-----•-------------------�:�.. �.------....... ... .... a= ---
cat�y'p{� ddress or Lot No.
- ....................... ----------------------------------- -------------------------------------_------
I �. DwnAfl Address---------- ......................-----.----
1, _
Installer / Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------------------------------•--•--•-----•--------•--•-•-•----------...---•-•......•-•...........------•----•.......------
Design Flow.................................gallons per person per day. Total daily flow ------------- ............................... gallons.
Septic Tank —Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter....____..__.__..._. Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. I... ............. minutes 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 ........................
Description of S
------------------------------------------------------------------------------------------------------------------- ---------------------------------................................................
-
Nature of Repairs or Alter�tiol�s —Answer when IT ble____________
---- 6.7) ---
Agreement: `
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1, 55 of the State Sanitary Code — Ila undersigned furtht agr of to place the system in
operation until a Certificate of Compliance has bee sued b e board of ke�l� � w
Application Approved
Application Disapproved for the
Permit No ....... .`.`.. S .
---------------------------------------------.....................
Date
Issued----------------- . ......_- ------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................................... OF.........%........................................................................
Qlrrtifirttt� of (f.outpliFattrr
THIS IS W, CERTIFY, That the Individual Sewage Disposal System constructed ( �r Repaired ( )
b 1.�n` I P`-tt `-
y � Installer
has been installed in accordance with the provisions of TITLE o T State S nitary Co scribed in the
application for Disposal Works Construction Permit No.......�_....-_5.�.__?'dated.._. �1a T
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE... / C� ..................................... Inspector:..v.:.--------•........................................................
IN
......... Fzs,.l.L..1:..
1 _3S THE COMMONWEALTH OF MASSACHUSETTS
__ -BQARD OF HEALTH
....... 1, Y*'"
Appliratian for lRisp.asal Warks Tonstrurtion JIrrmit
Application is hereby made for a Permit to Construct Q\) or Repair ( ) an Individual Sewage Disposal
System a
............... . .:J...-.-. ....... .. ,, T"= -- -- - - ........................
11-Locatio - dre� ---- or Lot No.
............................ ....
Address
...................••-•....... _ ..........�--��.-----------•------......------------......-----.....---------------------•--------------...
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ................ ...........__......-Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------••----•-----------------.---•-•-----•------..----------------•------...........-•-----------------•-•...............----
Design Flow .......... -,/%4Q .....................gallons per person per day. Total daily .flow ... ..... .. _G2 ............... gallons.
Septic Tank — Liquid capacity iI.".gallons Length ...... e._. Width.__....` _.. Diameter---------------- Depth .... ,_11....
Disposal Trench — No ..................... Width .................... Total Length.._._.___- -------- Total leaching area .................... sq. ft.
Seepage Pit No ... ............�_.. Diameter/d,.�.... Depth below inlet ... . .47... Total leaching area. fftj
Other Distribution box ( ) Dosing tank
Percolation Test Results - Performed by .............................................. -------- -............ Date..,%y ' '
Test Pit No. 1.c.-' ._minutes per inch Depth of Test Pit ..... _-------- Depth to ground wat r.....% .............
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
----------•------------------------------------------------------------------------------------••'--........ •................................................
Description of Soil.........
-------•---------------••---------------------------------'---------------------------•--------......_.....
--------------------------------------------------------------------- .....................................
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 TILT 1Z 5 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 Approved By .................. )Dal ... b...�... ---...----- �<!l^i 7 ....
Date
Application Disapproved for the following reasons-----------------------------------------------•------------------------------------------------------------•....
Date
PermitNo ......................................................... Issued.. ------------------_--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/�..OF..........`...r..j?.$ �yJ..11.(�1.7!.L...........
fitrifirtt r�a� f�a�t�rlitt�trle
THIS ..T_CE, .XIFY, That the Individual Sewage Disposal System constructed (,?51 or Repaired ( )
--.... r'..7..``................................................................
by ------ r . I staller
N
at-----------------_--- - ` ......................... -------- - ......... ........... ...... .------. -------- ---------•-
has been installed in accordance with the provisions of TI F _5 of T State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. �"__�.�............... dated._-_-_,',2,.�.�.......-..--..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector
i) - G /d%,)% /