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S M E A D
KEEPING YOU ORGANIZED
No. 12534
2-153LOR
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1111 INITIATIVE CONTENT 1090
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration -for Btsp ial Worko ( omitrurtion Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
...... ... ...........'k4le"'Z&.....IP44t .......
• c ion-A res - or Lot No.
. .. - -- _... .. ...... -•-----•-••-----••-•--••-•.•.--.•--•-...--•--•.----•......--•••••-•----•-••-••.-••--••---•-•--••
Owner --•--------•---------------••-•---.........Address
..��...... l -------•---------.
-- ---- -------- -
Insta Address
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 ( )
P4 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------------------------------------
a Test Pit No. 1................minutes per inch Depth of 'Pest Pit-------------------- Depth to ground water._..-__._-._-_______----
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ------------------------- ----------------------------------------------------------------------•••.........................................................
0 Description of Soil________________________ _.._.
x
U
x ------------------------- -------------------------------------------------------------------- --------------------- --•----- - - -- - - - - - ----
U Nature f Repairs or Alteratl s Answer when applicable.__--__ _ : '._.�.Q.®_la ____.___..- .
Agre en
iE= ---•---•----------------- --- -------------------------
The undersigned agrees to install the aforedescribed'Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary ode— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ee issued b the boar of ealth
r,.
Si
Date
Application Approved By------- -- - - ---- --- •- -------------•-- /l� ,�-,�"--7•. �
Date
Application Disapproved for the following reasons:-------------------- ---------------------------------- --------._-------------•----•--•-----
/ rr Date
Permit No.--••---•••••--•-•---•-------•-•-•--•---••-•.-•---...... Issued.._Id `-494__7.. .•
Date
4A t L% `
LOCATION. ' EWo.C;E PERMIT I.10.
VILLAGE
/AGE — —
iNSTQLLER1�S 1JQP/lE � ADDRESS
- - 1"� � �`—� oaf- - - - - - --
BUILDERS tom! [VAF— ADDRESS
DACE PERMIT ISSUED
DATE COMPLI &MCE ISSUED ; =
1
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LI ,
1 `
0
No...1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J OF...
Appliration -for Bhipaoat Workii Totuarurtiou Prmid
Application is hereby made for a Permit to Construct or Repair an �Individual Sewage Disposal
System at
Ala
... ........ ........
....................................
n-Ad es or Lot No.
e
... ...... ............... ........................................................
...........................
PQ W
Owner
... ..... ... Address
.4-1, _41.!'..14. .................. ..................................................................................................
Instal Address 41,
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder
Other—Type of Building --------_------------------ No. of persons..-___-_---__.______.___-.__ Showers Cafeteria
Otherfixtures -------------------------------------------------- ....................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity------------gallons Length................ Width..__........._.. Diameter_-._...._..----_ Depth................
Disposal Trench—No. .................... Width-_---------_-_----- Total Length_._..__.__.......... Total leaching area------------- ......sq. f t.
Seepage Pit No--------------------- Diameter..._.___.__......... Depth below inlet_....._____..._.__.. Total leaching area------------------sq. f t.
Other Distribution box Dosing tank
Percolation Test Results Performed by------------------- ----------------------------------------------- Date--.-.----------------------------------
Test Pit No. I--------_-----minutes per inch Depth of Test Pit...._____......_.__. Depth to -round water.-,---------------------
Test Pit No. 2----------------minutes per inch Depth of Test Pit.-._-_--__-____-___- Depth to ground water._.-------_-.-------_-.
P' --------------------__..................................................................................................................................
0 Description of Soil---------------------------_-...............................................------------------------------------------------------ ---_---------------
x
U -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------- ------- --------------I--------------------------
y Repairs Alteration —Answer Nature f R airs or Altera A r when applicable._!___11 . .......
_47 ................. ------j------------------------
A--------/er� —------ -
nt:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary,S:gde—The undersigned further wees not to place the system in
operation peration until a Certificate of Compliance has been vy e oar of Ossued b the board th.
S* ........... .. ....
Date
,24—--7-.J
Application Approved By_ --
---------------------- -------- --
Application Disapproved for 11 the followingreasons:------------------------- -----------------------------------------------/........Da,t,e-------------
L- -------- ------
...................................................... ------------ .............................._-----------------------------------------------------------------------------------------------------
Date
Permit No......................................................... Issued-----,( -2-F - (X--
. ............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ALTH
.. ......OF..................
Tntifiratr of W"I'limphaurr
7
THISI T 4C �TIFI-Qhat the Indiv* �I Sewage Disposal System constructed or Repaired
�4a, ew
by..........I .. .....
------------------------------------- ...
Istaller /--- ------------------ 77--------------------------------------------------
------------------;------- ....... ...........................
has been installed in accordance wit the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------- 1>4-j ------------------- dated'../0- ..........._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---------
................................... Inspector......_
THE COMMONWEALTH OF MASSACHUSETTS
O BOARD F HEALTH
> , , /7
...... .............. . ....... FEE---2—.............
U lioll afit
Permission is hereby granted.......... ------- �efn
..to Constryf) or.Repaiir an/lridi�,Qual Sewage Disposal
at No. 4111ft'.1, M- ---- -------- ��---------!_� �------------------
as7' S shown on the application for Disposil Works Construction Per t No.-.-. �........4 Dated__; 7 .........
A.........................
Board of Health
........................................... C/
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS