97 Applications & Permits No..z... .__..._.. FEE..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
E.
0 14
Application for Bisponal ellorks QQnnstrnrtinn hermit
Application is hereby made for a Permit to Construct ( ) or Repair (/ ) an Individual Sewage Dispos
System at:
1... ` '�. . - '
„ Location.Address or Lot No.
I
_......._..._.._..___._..:........—...... r-1 tr
Owner Address
�aq
Installer ller r Address
Type of Building Size Lot Sq. fi
U Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder
pale Other—Type of Building No. of persons Showers ( ) — Cafeteria
dOther fixtures
W Design Flow gallons per person per day. Total daily flow galley
WSeptic Tank—Liquid capacity gallons Length Width Diameter Depth
Z Disposal Trench—No. Width Total Length Total leaching area sq.
• Seepage Pit No Diameter Depth below inlet Total leaching area sq.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
W Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
a'
O Description of Soil
U
U
W f
VNature of Repairs or Alterations—Answer •when appligble r' ,:r sr '‘,"-1-z-1.r--- ��i.- .1 =`1
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance w
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system
operation until a Certificate of Compliance has been issued by the board of health.
Signed - !.,? . .
Date
Application Approved By i'_t '
. J Date
Application Disapproved for the following reasons'
Date
is 2
Permit No ! t Issued.: "` ,Dam
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�.6N OF /7,:
Prfifirnfe of Tit Rance
THIS IS.TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
plicttiun for Disposal Works Construction Permit No .�-G.'{ dated Y_..nr_.d/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
/STEM WILL FUNCTION SATISFACTORY.
\TE Inspector....
D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
y—
I� FEE
flispnnttl i;r;nrks Tunstriufinn Frrmif
Permission is hereby grant ............L:....s..._......;-:..i....._:y.'G.-7'° Cq
Construct ( ) or Repair ) an Individual Sewage Disposal System U
Street
shown on the application for Disposal Works Construction Permit No<: ' Dated
B6ard of 1 Ith
kTE
3M 1255 MOBBS & WARREN. INC.. PUBLISHERS
No > 7 ;- Fan
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
iTT , q
-q-r._of ems' ,_
il
Application for 13is#m ant narks fdnnstruuctinn 'Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair Kan an Individual Sewage Dispo:
System at: t2 �:.cr,< r,.,/ !
1.J a
Location. ...: 'sa or Lot No.if
_..........__...._.._t..:,._:.::_:..:_Co.�y...� - Address
WW J: :• Installer Address
1-1 cd Type of Building Size Lot Sq. I
U Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder
aOther—Type of Building No. of persons Showers ( ) — Cafeteria
a Other fixtures
d Design Flow gallons per person per day. Total daily flow gall(
M Septic Tank—Liquid capacity gallons Length Width Diameter Depth
x Disposal Trench—No. Width Total Length Total leaching area sq
• Seepage Pit No Diameter Depth below inlet Total leaching area sq.
2 Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date.
`"lj Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
{y Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
O Description of Soil
U
U
.�'� se
UNature of Repairs or Altera,�zztons—Answer when applicable `� .1!teC-s"-L =01*'f'^0 4 1,-44-
-1-tr AGE a _Al-kw IA..t.._4$:..ft�r�citc.tt Lr I
Agreement: r_ /
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance ,
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the systen
operation until a Certificate of Compliance has bee&essuedy thekpard of health. 'Ij,
tiN
C� !1[ f'�i . ' U
Signed .^W! NY
Application Approved By ' . - ids, �„ n <) 2
Application Disapproved for the following reasons'
� mate
Issued...-L=- ,11.- ' 'S »L /
Permit No Dan
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
f ertifiratr of ((Sampan=
er
THIS IS.TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (' )
Installer
been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
plicarion for Disposal Works Construction Permit No -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
!STEM WILL FUNCTION SATISFACTORY.
kTE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
of 71.0.
"4_
flispnsa tii,arks (Tionstrurtion 'lJermit
Permission is hereby granted.. / -- %' % --IL.'
Construct ( ) or Repair on Can Individual Sewage Disposal 'System
No
7 .T ,.
Street
shown on the application for Disposal Works Construction Permit No Dated....L.I.It ✓ s(k.1
,. 1 -� and atn=2 CInTA
Bwrd of Health t,y
FEE
STE
tM 1255 HOBBS & WARREN. INC_ PUBLISHERS