11 Applications & Permits No._1_(
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Fitz .
Application for Biopooal rs orlw Qlnnotrtirt" n tiPrrnit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
14
Owner
U . t
_...._..___.....__...L.d Installer
Type of Building
Dwelling—No. of Bedrooms No. of person
Other—Type of Building
Other fixtures
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Design Flow
gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons
Disposal Trench—No. Width
Seepage Pit No Diameter
Other Distribution box ( ) Dosing
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch Depth
Test Pit No. 9 minutes per inch Depth
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
tank ( )
Description of Soil
Date
of Test Pit Depth to ground water
of Test Pit Depth to ground water
Nature of Repairs or Alterations Answer when applicable-,-.41 4.4et d"'' ='I
.>•ct l3 d
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
Agreement:
-,
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.:.._:.':L
r & , Gv-t.(
in l
Application Approved By >.`/- ,�.�-��=-AZ._rF� ;Se
Application Disapproved for the following reasons
Date
N� x�,.i 'r
�"�Date
Permit No ) ' r
Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
!. L OF 1
dErrtitir of OUittpltantr
THIS IS 7 0 LEP 1", TJnat ndicidual Sewage Disposal System constructed ( ) or Repaired (16
Installer
at
has been installed in accordance with the provisions of Article'X� YThe State Sanitary tCode as d 3 rated i nthe
application for Disposal Works Construction Permit No
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. t i
DATE - )1 Inspector
�, � E ___
% //. -&
No
Biripanatilliarits ggtl trurtilltt hermit
Permission is hereby granted;,.. '
-H-4s 7 76 . ,"u
to Const ruct ( ) or Re pair —- - --—
(I') an Individual Sewage Disposal System
at No -r-'`fir ! ', . .. St t
as shown on the application for Disposal Works Construction PPinpit No -IL Dated 1 '.� /-f
- ..' .. _
Board of
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF i/jOierten,rs% 65
J ..
FEE
DATE
FORM 1255 Hoes& & WARREN. INC. PUBLISHERS
Fa
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application fur 3itipniiaf Hi arks (ltnnstruttiun lJermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
1 . F
Jei
Of Lot Nu
Ib:'Rtlon-Addrtn
., « :.'Zl Address
rn
ntcr Address
Installer Size Lot Sq. feet
Type of Building
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
P
Other—Type of Building
No. of persons Showers ( ) — Cafeteria ( )
Other fixtures Mons,
Design Flow , _ gallons per person per day. Total daily flow g°
Septic —Liquid capacftJ"� ''% ga llons Length
Widt Diameter Depshr,
Dispo sal Tr ench
—No Width Total Length Total leaching area...7 I "' sq.ft.
Seepage Pit No Diameter Depth below inlet Total leaching area . sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Data
Test Pit No. 1 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 Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of Compliance has been issued by the board of health. r
_i. i C . ,N , �.
Signed ' ' « :
v ri
Application Approved By J
in accordance with
place the system in
it
Application Disapproved for the following reasons-
Permit No
Issued
mtf
h
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Tertifirate of anmptiaure
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 N[ 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.
DATF Inspector
No /
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Uispnsal rr irks Qinnstrurtinn ertt}it
Permission is„ granted
to Construct (f) or Repair ( ) an Individual Sewage 6isposal System
FEE
Street
as shown on the application for Disposal Works Construction Permit No / Dated
DATE s:• r L
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of He4Eh