401 Applications & Permits A
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
alt or No i.HP.Ph°Tr_ ,.
Application fur 3)iupunal ifiurku Tunutrurtiun 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
rstent at: O
or Lot No.
Address
-_YON^` ....._ _o-'6L.t.!---..__.._......_........ Address Sq. feet
'ype
Installer Size Lot q'
'ype of Building Garbage Grinder ( )
No. of Bedrooms Expanson Attic ( ) — Cafeteria ( )
Dwelling No. of persons Showers ( )
Other—Type of Building
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Depth
alloys Length Width Diameter P
Disposal Tank—Liquid capacity i Total Length Total leaching area sq. ft.
Width Total leaching area sq. ft.
Disposal Trench —=�°� Diameter Depth below inlet
Other Pit Ntio_____ Dosing tank ( )
Other Distribution box ( )
Percolation Test Results Performed
per d by Depth of Test Pit
Test Pit No. 1
Test Pit No. 2_.._. minutes per inch Depth of Test Pit
Description of Soi
Date
Depth to ground water
Depth to ground water
Nature f Repairs or Alterations n Answer hen a licabl a-,..y .- -a_ srtro
Agr�nent:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitar Code-The undersigned
board o d further agrees not to place he system
operation until a Certificate of Compliance beeped by
t Wed /�^'•_ ,
g :jam• �/� L lLo .....f/V9 r/����"''''"""" �/ '� Date
Application Disapproved for the following reasons' Dam
Application Approved By
Permit No
Issued-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ......... ......
Ottrtifiratr of Olottiplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
y.............................. .-..............
Installer/
tas been installed in accordance with the provisions of TITLE, 5 of The,State Sanitary Code as desciiibed,in the
.............. . .... ............................................................................ .
mplication for Disposal Works Construction Permit No..................................... dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTERTHAT THE
SYSTEM WILL FUNCTION SATISFACT,ORT—
DATE............................ .... '1' Inspector........ ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Disposal I N arks Tonstritrtion Permit
No
Permission is hereby granted
to Construct ( ) or RepalkLL 1-an Individual Sewage Disposal System
atNo. .. . . .1...... ......... ............... .............. .. ... ............
as shown on the application for Disposal Works Construction PersttnutreeNo. ..... . Dated '
Board of Health
DATE .................................................................
FORM I255 A. M. SULKIN, INC.. BOSTON
THE COMMONWEALTH OF MASSACHUSETTS
HEALTH
BOARD OF
oF
Nvpikentt for tiovooal kG orko Tongtrurttotl permit
or Repair ( ) an Individual
Sewage Disposal
Application is hereby made for a Permit to Construct ( )
tem at:
yoI
--" -"
t�p?
or Lot No.
•
Address
Address
._- Sq feet
Installer Size of...........................
Garbage Grinder ( )
tpe of Building - .. E pansion Attic ( )Showers ( ) — Cafeteria ( )
llwer-Type of Bedrooms
"" No of persons - ._
Otter—TYVe of Building __ - -- .., gallons
gallons per person per day Total daily flow Other fixtures . Diameter _-. De xh - - s.
O Width_ �- s4 Et.
septic Flow_- - - [y gallons I ength _Total leaching area.y
I_ and capacity%)a g
_.. Width_f q,__—_Total Length. -'
lcptic Tank— 1 ,_.. Total leaching area-_.____..
sq 7isposal Trench 10. ---- Depth below inlet— - -
-__ Diameter..._._
)there Pit No -- Dosing tank ( ) - _ Date,
Distribution box ( performed by -' -" - Depth to ground water ---
Percolation Test Results . _ Depth to ground water
Test Pit No I minutes per inch Depth of Test Pit __
Test Pit No. ?-----_minutes per inch Depth of Test Fit —
Description of Sot- - ----
Nature of Repairs or Alterations Answer when applicable -.
Agreement agrees to install the aforedescnbed Individual Sewage Disposal System in accordance with
The undersigned g ns f ^rtu
ed by th Id/p Y`""' '
the provisions of Article XI of the State Sanitary Code—The undersigned further ages ? to place the system in
-
✓r __.aj}��^� _._._
operation until a Certificate of Compliance has b
if YJ
igned - ...- _
two �r �
Co Date
dY�
Application Approved By .- -_ _ - - -—
Disapproved for the following reasons.
nt
Application DtsaPP [�1
. - - i Issued.. � Date
_Permit No_'_'_'._______....._.__._....--
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF . u'
Certificate Of Compliance t/ Repaired THIS IS EVE ERT PY,Tlr4 theg ndividual Sewage Disposal System constructed ( ) p ( )
✓. -7) tii
at y r
has been installed in accordance with the provisions of Article The State Sanitary ,ode as rib m the
dated application for Disposal Works Construction Permit No 11 V
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ._.,,t j,Y/
NA-z/ <. G. I
Inspector
U:1TP
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r2{y vy OF , rt,�/ }rti�1.C.1 Fry
NO Works Uthpugat Thurks Cunatrtttti0tt Permit
. i
Pestruct ( is hereby granted Sewage'to Construct (yt or Repair ( ) an Individual Sewage DtsposaT System
Street
at No
as shown on the application for Disposal Works Construction Permit No - .-r Dated
m
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS