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LOCATION' s V 0 c eFei e'rI yr el C Ay C SEWAGE #
VILLAGE (,t ASSESSOR'S MAP & LOT QP(t I
INSTALLER'S NAME & PHONE NO.
SEPTIC. TANK CAPACITY / go v 6ZZ
LEACHING FACILITY:(type)� (size)_
NO. OF BEDROOMS PRIVATE WELLS OR PUBLIC WATER
JdIIILDER OR OWNER �/�� A
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:_
VARIANCE GRANTED: Yes_ _ No__i
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LOCATION ' SEV\M,CtE PERMIT UO.
It�1STAl_LE S 1JDME � ADDRESS ,^
BUILDER 'S Q &MF- ADDRESS
DATE PERMIT
DATE COMPLI W,4CE ISSUED : �2 - 1-2-76-
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No..... -------• Fs$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 06 HEALT
__.. . ... ---....OF.............. �. -...
Apphratinn -for Bitipaasal Workii Tonstrnrtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
Locafo �,}dr s � Lot No.
�� "
. 1
w er V, Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type 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------------gallons Length................ Width.__._..-.-.--_.. Diameter_____..._._.____ Depth----------------
x Disposal Trench—No. .................... Width-------------------- Total Length------------------_ Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-- ......__________ Depth below inlet.................... Total leaching area_-.-__._.-_____-sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by_-----------------_--------- ------------------------------------------ Date-----_---------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water........---------.......
(4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
W ------------ -- ----
ODescription of Soil---------'-------------- -- ----- `-----------•--------------------------------------------------------------------------------------------------
x
U --------------------------------------------------------------- --------------------------------------------------------•---------------------------------------------------------------- -------------
W
x ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature 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 Article NI of the State Sanitary Code— The and rsigned further agrees not to place the system in
operation until a Certificate of Compliance has b n ' ed by th oar of alth. !/
igned- - -- -- '
Date
j Application Approved By ..... e -- ---- ...�. ._ e
Date
Application Disapproved for the following reasons:........................................ .....................................................................
-•----•------------------------------------------------------------------------------•--------------•-•----------------------------------------- =
Io Date
Permit No--------------------------•----------................... Issued..-----------------Date `
... ------- -•-
------------ ---- - --- - -
No............ -------- Finc..c-L.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OV HEALTLj
----- -- OF..............
Appliratiuu -fur Biipuuttl Workii Tonfitrurtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System�/ a�D (� �G... I'
�� _/'_ --
Locatio •eldr s Lot No.
� w err, Address
Installer Address
UType of Building Size Lot.................:.........Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons-_-.-----•________---__-__ Showers ( ) — Cafeteria ( )
Q Other fixtures --------•------------------------------------•.......
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic "17.ink—Liquid capacity------------gallons Length................ Width................ Diameter-------.-------- Depth...--__......_.
x Disposal Trench—No__________________•_• Width-------------------- Total Length__-__-----__-__--- Total leaching area.-------------.-----sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet-------------------- Total leaching area------------------sq. ft.
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...-_-..___--.-..-.----.
rJ. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__._..._-_-__-.__-__--.
W .............•. -W O Description of Soil..--- •---------------- . •-----•------...---------.......------. -----------------------------------------------..------------------------
x
U -----------------------•--•--••----- ....-•------------•----•------------------•-••------••-----•------•------------•-•.....---------------------------------------------------------------------------
W
U Nature 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 Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has n ed b th o
Y a of alth.
igned
r
Date
Application Approved BY ----- ---- --•-•• -• �'�> 7
Date
Application Disapproved for the following reasons-------------------------------------- -- ...................----------------------------------------------•---
-•-•-•-----••••---------••--•----------------------•---------•-------•----------------•••----•----•----------------•-----------•-•--•---•------•....------•-•--------•-•------------..................
Date
PermitNo......................................................... Issued.......................................................
I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ?F HEALTH
....... '& . ........;;OF.... ..............................................
Tntifirate of Tomplitturr
T CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by-' ---- ---- -- - ------------------------- .........
----- -------------------------------
at--- . ...... . ... . .... ... U
----------- .4
has been in alled in accordance wi Atihe provisions of Article Xi of�Ihle State Sartitary Code as described in the
application for Disposal Works Construction Permit No._ ------------- d,-Lted..-.,,-/- ............
--- .... ... -------
117----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.---•------•-••...............•--------••....•--•••-------•-----•••--=-••-•-.... Inspector.....................................................................................
E COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
OF.'!i��..........�'..........................................
No.--------- 6 FEE.,2,.................
Permission is h reby grante ...... -A.... . .... -------y... ....................................................................
to Constr a' Individual Sewage
---- . . . ........
at No��_.M....:.... ( A
reet
as shown on the application for isposal Works Construction Per o--------- ---------- �jted....
...... ....... --- ------ ................
ar He
DATE_f�.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS