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_5EW&'C4�IE�PERMIT 0.
INSTALLER 5 1 WE P, - ADDRESS
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5UILDER_5 Q.&ME 4 ADDRESS
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pIs,TE PERIA T 155UED --;Z—1 1.iL--
D ATE COMPLI &&ICE ISSUED : 3/,
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THE COMMONWEALTH OF MASSACHUSETTS
EOARD F HE
.. .........0F...... ...... ... ............. . .... ..............
Apphration -for Uri viral Works Tonstrurtion rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systemat: .................................................
Lgcation-Address or Lot No.
Oer -----------------------------------••-----•-Address
a .......-• �. '�.. - - -- '--....----•.-'.-•.----....•-'--'-•'---•-
Installer Address
UType of Building Size Lot----------------------------Sq. feet
No. of Bedrooms...-_.-.-_--...Z- ...... .............Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------- No. of persons_.--------.-._..-.-..------ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------ ------------------------ - -
W Design Flow---------------------�70................gallons per person per day. Total daily flow.._...--.-__-----.�.Q.b..............gallons.
WSeptic Tank—Liquid capacity....- allons Length--_-__-__--_-- Width................ Diameter................ Depth----------------
x Disposal Trench—No. .................... Width---..ST p_�Total Length._..-..._..-_-_----- Total leaching area--------------------sq. ft.
Seepage Pit No---------- _..._.... Diameter.1000__p4 I th below inle ............. ... To leaching area-------...........sq. ft.
z Other Distribution box ( ) Dosing to°� ) d� • ��� — 7 j--
�" Percolation Test Results Performed by-------------------------------------------------------------------------- Date.-------------------------------------..
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......-----------.......
f� Test Pit No. 2................minutes per inch Depth of Ast Pit.................... Depth to ground water........._-.------_.__.
---- -------- -'----. --.........• -----'--•••----...-"......----•------•----
O Description of Soil----- 40 `..a2.u = T
U ------------- �-� �-••--t...... . ...... ..... ....... ......... ------- — ---
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 \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ed by the boa d of health.
gned------ . .... ..-- . ` --
Date
Application Approved By..-...----- ----- --•-••. '-• -'-• �- ....17 ./--- .. - ---- _
Date
Application Disapproved for the following reasons-..................................... . ----------•---'--'------------...........•-'•--•--•---•'--•---
--------------------- ......................-.........
Date
Permit No.......................................................... Issued....77-T�" 7J
1. _��_�__.�___----------- Date
_ ------- -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE
-_._......OF...... .4e ........
Apphration -for :41-4puiittl Works Towitrurtion Vrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
{� Lgcaen•Addres�r� or Lot No.
..........-
.. -•• ............................................ ..-•---•........................ -----------•-------------•----•--------.........-•--
. j� Ow er Address
Installer Address
Q Type of Building Size Lot----------------------------Sq. feet
U ( ) ( )fD.,,�yellin —No. of Bedroom�'j_�_________________�-.._..__..__...___..._Expansion Attic Garbage Grinder
aOther—Type of Building _-d.�...................... No. of persons............................ Showers ( ) — Cafeteria ( )
A'' Other fixtures --•------.--•-• -•-----------
W Design Flow___________________SQ._...._........_gallons per person per day. Total daily flow------------------ ..............gallons.
WSeptic Tank—Liquid capacity______/60'zg'allons Length................ Width................ Diameter---------------- Depth----------------
x Disposal Trench—No..................... Width------ P_jotal Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No----------1--------- Diameter_/D�Q__ _ Seth below inlet............. Toxn leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tan ) �,� ��� — ��-1.7-- ;;p
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
.a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water...................
rX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground
xa' 'r -
water_-.__._`_"___`____------
•------------•---•---•--------- -
a �
Description o Soil----- •-----. ....... ---- ----- -• -•----•--
...
�----•-----------�- ........... -----.. .� ---- •--- `� ` - -----
v 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 XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ed by the boaald'oof/health.
Date
Application Approved By........... - -•--- - ---- •. ........ -- ...... _ -- ------ ----�---/--•� 7 ...�
Date
Application Disapproved for the following reasons-------------------------------------------- -----...............................................................
------------------- ------------------------------------------------------------------------------------*--------------------------------------------------------------- ...............................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ALTH
77��:............OF.................. .. ...... ....1�....' -.—:................
Trr#ifiratr n =' V ianrr
IS S TO CF �f�FY Ch t the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ...... �.-=`---� � ----. %
2— Installer /
lJY2. /
has been installed in accordance with the provisions of I
of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___._....f I _�................. dated-.._____7_'. ......... ....._.
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......... 1✓ Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O� HEALTH
J I......O F.......... a16--L-
/J
N l ... o FEE /�1..
Ri-C-5100,i ark, r r ant Vrrutit
Permission h eby granted ------•--- -.-• '.. .. .......... ..
to Constru ( oRepair V J �ividual Sew e Disp s Syste
at N
Street yy
as shown on the application for Disposal Works Construction Permq�oard
_ Dated___.__/---- ...._� .
-------------- ----- ..._.....-----•-••--..
of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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