372 Title 5 Applications/Permits, 1963, 1972 f
4.
1
4.
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
?.0 7 rJ app •
Fn
Appliratiun fur Jispmat re arks Cnunatrurtiun permit
Application is hereby made for a Permit to Construct ( ) or Repair (I-') an Indic idual Sewage Disposal
System at:
Lot sr.
y ff owner
Address
—L.:li� ,f e& etatI i
11¢ ALdvess
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
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.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dispo.al System in accordance with
the provisions of Article XI of the State Sanitary Code—The uncle igned further ag ces not to place the system in
operation until a Certificate of Compliance has bee issued by the bo d o
Application Approved By
Application Disapproved for the folio
ng reasons -
Permit No `51-3
Issued ktei...7))
ECK OR FILL IN WHERE APPLICABLE
NO FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Appliratinn for Disposal
rr;
larks Tonntrurtiun hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
Location-Address
;LP_
or Lot No.
net :J // Address
x.^r�f
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 ( )
Other fixtures
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.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
In
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
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 Article XI of the State Sanitary Code— The unde igned further agrees not to place the system in
operation until a Certificate of Compliance has beent issued by the bo d of j
Signed.... r La's f '_4 eta it.
d—.6., . r / . ^ ; Date - 7
Application Approved By :.e.yra.t4.....f:L....r.al 2.a..0d41-- timer,: .r.e---
U C,
Application Disapproved for the following reasons•
Permit No Ss
Issued
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
QOrrtifiratr of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of Article RI of The 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
No..L7-1 3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-
OF
Oispns/al arks Tonstrurtinn lirrmit
Permission is hereby granted.. ..�:�c.:..Ce...._�tr•-
to Construct or Revak (-Ca—an Indipd4 Sewage Disposal System
at No ..a-
street
as shown on the application for Disposal Works Construction Permit No 1._6 Dated...'
Board Of Healthy
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application for Disposal
II;I;
arks Olonntrnrtion Derma
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
In got;-Adder
or Lot Na
Address
Installer Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building .9 eNo. of persons Showers ( ) — Cafeteria ( )
Other fixtures �.CA-C!RF4 teas-C`lkle`--
Design Flow gallons per perso45 per day. Total daily flow gallons.
Septic Tank—Liquid capacity- I gallons Length Width Diameter Depth.. __...LL.......
Disposal Trench—No. Width Total Length Total leaching area.../--.- i t4.ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by Date.
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
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 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 boydldgof hea]!h. L`
Application Approved By
Application Disapproved for the following reasons
Permit No Issued
Date
7
by
at
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
((Certificate of ((Compliance -H-6. wit -
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V) or Repaired ( )
3 �
- /
has been installed in accordance with the provisions of Article. of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No Y dated 1 -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE i ' - Inspector _
No...;
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Elisposal ril urko (IIonntrurtinn Permit
Permission irtlereby granted
to Construct (t ) or Repair ( ) an Individual Sewage Disposal System
at No -
FEE
Street
L-
as shown on the application for Disposal Works Construction Permit No -- L Dated
DATE._, i • .,.-
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of Heath