795 Applications & Permits No...4
FEE
THE COMMONWEALTH OF MASSACHUSETTS
&Z/BOARD JJ OF H EALTH
OF
Application for Binomial 'Parka alonstrurSut Vaunt
rib
Application is hereby made for a Permit to Construct ( ) or Repair ( ran Individual Sewage Disposal
System at:
2 Y • T or Lot No.
it] q, Owi Address
CC
mllea Address
U• Type of Building Size Lot Sq. feet
.] Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
W Other-Type of Building No. of persons Showers ( ) - Cafeteria ( )
C Other fixtures
Design Flow gallons per person per day. Total daily flow
W 77 j g" P P Pe Y Y gallons.
g Septic Tank—Liquid capacity./._4.f(.gallons Length Width Diameter Depth
Ill
• Disposal Trench—No. Width Total Length Total leaching area sq. ft.
3 Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
zt Other Distribution box ( ) Dosing tank ( )
.1 Percolation Test Results Performed by Date
.l Test Pit No. I 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
g
x• Description of Soil '
U
W
U Nature of Repairs or Alterations—Answer when applicihle` A_
Agreement: •
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitar Code—The under igned fur her agrees not to place the system in
operation until a Certificate of Compliance has b n issued by a jAa
Sign O.-
Applif�1 �Application Approved By Date
...0 .2 /9�s`
Q (J Dat
Application Disapproved for the following reasons.
Date
Permit No 33 Issued
Date
b
at
has been installed in accordance wi h the provisions of Artc I of The State Sanitary de s sferibed.in the
application for Disposal Works Construction Permit No / a 4 dated:'.. us+ / YG.S
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UA ANTEE THAT THE
SYSTEM ri2LL FUNCTION SATISFACTORY.
DATE i /J IS Inspectors n
THE COMMONWEALTH OF MASSACHUSETTS
BOARS OF EALTH
OF
(Itrrtifirttte of fQamplinnre
THIXU1 T ICER II Phalle Individual Sewage Disposal System constructed ( ) or Repaired V
7 13 9/k 2/Li fr41 C;?S
Installer
THE COMMONWEALTH OF MASSACHUSETTS
BOARD� OF EALTH
OF
Dispunt, rks ,[nu tr rtian lrrmit
Permission a hereby gr'"'�y,1/
to Construct ( ) or Repa}r� (' an Indi u��u'dna igg�Disposal System
at No 71 X n
as shown on the application for Disposal Works Construction mft No /`3 yr Dated_._ °1� '[b
Board of H
FEE
DATE
FORM 1255 HOBBS 8 WARREN. INC.. PUBLISHERS
Ems/
THE COMMONWEALTH OF MASSACHUSETTS
^--T��--t��./// BOARD OF HEALTH
Ci i , / OFAA-V4774/141370/1/4i
Oration fur 3flin{Innni Mirka Cnunntrnrtiun Ijrrmit
App ication is hereby made for a Permit to Construct
`System at:
w
e
or Repair (KCIndividual Sewage Disposal
R p. -it ?73
IS 6 'l
PVC-
Instal cr
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons
Septic Tank—Liquid capacity-ldde altons
Disposal Trench—No. Width
Seepage Pit No 1 Diameter
Other Distribution bow.— Dosing tan
Percolation Test Results Performed by
or Lot No.
Address
Address
a Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
per person per day. Total dail flow gallons.
Length/'' Width Diameter Depth
— Total Length ^ Total leaching area sq. ft.
Depth below inlet...J..fo tl Total leaching area sq. ft.
WerAs p' /- -)i !late
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 Soil A01".... ._.RE S%R._ ` 43 per._- - -
Nat re of Repairs or Alterations—Answer when a plicable CE u&t5./.1
{ icla 6- PIT._(I AL.t ) A100 So 0,0 cialceitio
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
is ed by the b;rd of l zd 1.-)
operation until a Certificate of Compliance has 11€en
Application Approved By
7/i4/f.C)
Application Disapproved for the following reason'
Permit No
Date
Issued
Date
THIS IS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifiratr of Qtamolianrr
eb CE F }E-the Individual Sewage Disposal System constructed ( ) or Repaired ( O
by BS v�
j I
at Installer _
jr1�
has been installed in accordance with the ovisions of T_7::b ' f The State Sanitary Cncl des ibed in the
application for Disposal Works Construction Permit No_. ..`/Tr2/dated3 `L°
THE ISSUANCE OF THIS CERTIFICATE SHAL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU C I_ ,ON / i
DATE C� Inspector ✓
No ?&
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL
L t(,
or AO: r G �� T-✓�
U
Permission is hereby granted ( �4Fh"' g:/ ! ! L. tt
to Construct ,f-1 Repair n Ivvl(tai Se 'DisposxF7$on
is ork ACC
at No ... ... . ,�
so- a C
— G !.''11
% j . Da . .�_ .. V
as shown on the application for Disposal Works Construction P J/ J -
!t 1` i I/ ?or: C. Board o u�w
DATE s_
C
FORM 1255 HOBBS & WARR EN. INC.. PUBLISHERS
FEE