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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
- .....................................OF...... t.v- .. .............................................
Appli rtttann for Baiplas al ork i Tnnitrnrttun ramit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
Sst at: ............ .............................................. ••--...... .C_e. .
.....L.o.c ti n�•Address or Lot N6.
W �a � — Owner = ........................................................
Address
_— �..Z ,
.• ------------------------•-•-----•--------- •- ........... ._.. ....�.....---�
Installer Address
Type of Building Size Lotl6_000......Sq. feet
,., Dwelling—No. of Bedrooms............................................Expansion Attic Ale Garbage Grinder Mrs
Other—T e of Building ............. No. of 'Persons............................ Showers — Cafeteria
Q' Other fixtures .---....._--•-• ---•--••----... . -- ..--
W Design Flow.......... '`.. ...................gallons per person per day, Total daily flow-------_ �_._� .._______ __..........gallons.
WSeptic Tank—Liquid capacity/r?R gallons Length.K 7._ Width....jk._._... Diameter................ Depth...A?........
x Disposal Trench—No..................... Width.................... Total Length...........,...;.... Total leaching area....................sq. ft.
Seepage Pit No......./........... Diameter..../f..._....... Depth below inlet....... ......... Total leaching area..0;2.v j(....sq. ft,
Z Other Distribution box (�) Dosing tank 'O'
'-' Percolation Test Results Performed by...7 re...................... Date.... _ ! 1�
Test Pit'No. 1....�_------minutes per inch Depth of Test Pit................... Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a �.
x a . t..... ..
ODescription of Soil-----•......--•-•- • -------- ................................... .-
.....--•--------------------------------------••----....----
W -----•-----•------------•--••------•-------••--••••---••---------•••-•-•-----•---------•---•-•---•--------•--••------•--••••----....----•---------••------•-•••---•---•-•--•------•-----•-...--••-----•-
UNature 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'ITT,,.,. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n issued by the f health. !�
Signe ...........•-• �D�,�-•-•--.....
Application Approved By......... .....1................... ...................................................... ...... ` 7-----
Date.
Application Disapproved for th following reasons:-----------•--•--•----•------------------------------------•-------------------=--- ............................
...---•---•-•••---------•----.....•................•••----•-------••••--•--------•-••--•••••••--•--•----......-•-------------•-•••-••--------••-•-••....•--•-----•---••---._.-_...._....._•------•------
Date
PermitNo------•`u;,....----....-•------------------------- Issued---------------......................-•-----------•----
-� Date
T
§.s 3�q hj/P `r10 y a 3
LO C �"l N SEW A C E PERMIT NO.
Z-l 3.?Z _
VIL SCE
INSTA LLE'S NAME i ADDRESS
r
BOIL ER OR ER
DATE 'PERMIT ISSUED
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS 3t
BOARD /OAF HEALTH
//
...C/.. ..7�..........OF........ Gl(..dam...);....�,-� _.�r.j_.L..P ..._........
Apt for 11ispoii al Works Tonstrnrtinn ramit
Application is her made for"a Permit to Construct ( or Repair ( } an Individual Sewage Disposal
Syst at:
.. ..?.....s........ :' Q4. -
2,,.................•-•--- a.l....------..ez..4� r�....
•- ••. LocAddss or Lot N
OS � ...✓...............^,-- �Z• /�� l�x�y: ....... r/._. ram? ., .�ri
Owner Address A fj
w ---•................................•------.........................__......._........-----....... ----•-----.......--•.................--------•------------...............!. �...
F4 Installer Address
d Type of Building Size Lot ,( 70_C20......Sq. feet
aDwelling—No. of Bedrooms.._......_. ..........................Expansion Attic / a Garbage Grinder
pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ............................
W Design Flow..........�'lf..'....................gallons per person per dal. Total daily flow_....... ._ _. __.
� �t�--------- ------------dons.
WSeptic Tank—Liquid*capacity/t9P.Qgallons Length..,F.._.�_.. Width.....(........ Diameter................ Depth...!........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....... ........... Diameter.... .__........ Depth below inlet.......(a......... Total leaching area.0;2_0_1....sq. ft.
ZOther Distribution box (/) Dosing tank p
Percolation Test Results Performed by..�t`= �?J�_!�� �! ......._ ,ll/ter.
_a.17-S........
�, ..�--- Date_...
aTest Pit No. I....ca?...._..minutes per inch Depth of TesY�it.......1......... Depth to ground w ...................._...
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fyi ........ .........................or
D Description of Soil.................. c� ._d.... �............/.kts.�
(xj ---
--------------------
•...........
--.--..---------------------------------------
•----------
•-•-----........----------------------------
•--------- ...........
•---------------
• ------------
W ----•••-••-•-----•••--------•------••••••••-•-•••._...••••----•••...••--•--•••••••••-•-•---•---••••-••---•-------•------•-••••••------•--•--•---•--•...-•••••••••-••-•-•-......-••-••......-----•.....--
UNature 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 TIT1:;. 5 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...................................................................................... ..........................
fate
ApplicationApproved By..........1 �•-�-1K..........................•--------•------......---•---•-----•-•-••-----. ........4'----- -- e x
„ Date
Application Disapproved for the following reasons----------------------------------------••---------.......__.....---•----------------------..Date......---•---
.................•••-•----•-----------•------._.....-••-•---------••........-•••-•-----••--------._........-•--•-••---------••-----•-••-----•-•••-----•••-•••••-----••-....--•••-••••--••-••-----........
Permit No.......3-111»----.----•--•-------------•----------- Issued.---•--------....zl•.•-.7��._.'..Date......
Date
THE"COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
dd _:...........OF.......... ............................ .................
........
s. Trrtifiratr of TontpfiFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at............ t
� .�' �"' �'. . 4 �s4-a r as/lt!---,.... ��� ........................ --------
has been installed in accordance�w�th the provisions of TIT 4 :>of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No:_` ,j7" ........................ dated......... ......................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM W1�1,JUNCTIQLN SATISF CTORY.
--•---------------------r ......
DATE Inspecto ----_---••-
THE COMMONWEALTH OF MASSACHUSETTS
y; BOARD OF s HEALTH
G44 O F......��l r f1'�'
.............
... �..........
No......3.3 FEE...." , .. ...
Disposal Worb Twunstriirtilan rrniit F
Permissionis hereby granted..............................................................................................................................................
to Construet4 ) or Repair ( ) an Individual Sewage Disposal System
atNo........44.r------.---; ---- -----•- ----- ---- - -Street--- -----•------------••---------- --- --
as shown,on the application for Disposal-Works Construcrion°l'Permrt No,.,•? --------- Dated.....
......................•-•--......-----------------------------•--............................,...... .
_....-•----...--•---------------- Board of health
DATE--------C' .....• ---•-
FORM 1255. HOBBS & WARREN. INC.. PUBLISHERS /'
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