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No. -7..x• FizIc .. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ��HEA�LTH�
........of ....... .. ........................
Appliratiun -fur Ui,ipuuttl lUorks Tomitrurtiutt Prrnift
Application is hereby-made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy at:
Loc ion•Address /I�t No.
Owner Adcj ss
- --•-•--•------------- --------- -- ...------- . ----• .............------------
Installer Address
d Type of uilding Size Lot.16`------------------Sq. feet
v Dwelling—No. of Bedrooms...�...............................Expansion Attic ( ) Garbage Grinder (*0'
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/—'ViPgallons Length................ Width..--------- ... Diameter-.:----_------- Depth..-----_-_---
x Disposal Trench—No- -------------------- Wid h.................... Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No---------------------- Diameter.r..�. -... 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-----------..----------.
r3:4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.....---_---------. Depth to ground water........................
9 /r - - f
---- -
O Description of�o Q-`-•- - -- `
x h�tc .�rGf Viz '
U
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 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 isskiedby the board-of heal- . _ 9 n
Sl �07 oleo
....... ...... . .....
te
V� �"7
Application Approved By. �................ � - --- T
Date
Application Disapproved for the following reasons------------------------•--------....-....-------------......-.........----------------------•-•-----------------
.....--•••••.---••-•-•......................•-----------------•--•-•--..........•-•-•--•-....--------•-- •-•----------------------•------------...-.......-•-•-------------------------•----------•---
Date
PermitNo......................................................... Issued--- .. ..........................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
No......... ....`.........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
r " r lr� •............0F..........,�:. ?! _rr.:. / f
Appliratinn -for.13i,gVunttl Work,6 Ton,strnrtimn Vrrniit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
r
Location_Address "Ior Lot No.
".... - -.__.. ----••------•------------ --------------- -•---------------•--= ---------------._...-_..:.....
Owner /"/ - Address / r
� � f Installer Address .
Q pe of Buildin Expansion Attic Size Lot_-Garba e Grinder feet
, �' Dwelling gNo. of Bedrooms----°�'�. p ( ) g Sq.( )
aOther—Type of Building .-______ ____________ No. of persons----------------------------- Showers ( ) Cafeteria ( )
QOther 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---------._-._.._-._...
(14 Test Pit No. 2,________________minutes per inch Depth of Test Pit-------------------- Depth to ground water__.--. ----.--.--__-.
�N� •� f
G p`j1 SO Q ' r �Y- ff--
- �'� ` ' r ` ' ,7 f— '; -- td�Descri Description of 1• r (° _
x ------------4 -- .+, r. tf± "" A ' .. +►,�_: - ---�'2 --- -- <"
CU
•---------------------------•-------------------•-••----•-•-•------------------------•-----•-------------------•-•-----------------------=--__._-------•--------------••------•--•---------------------
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 Article NI 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 the1ciard,of,health.
V. l
rr r SJI C --Ls ___/--By.:- � .. ------f•�- '-`-•_ --------------------------------
ate+�p
?Application.Approved `
#. Date.
Application Disapproved for•the following reasons---------- -----•• ---•-------------------------...................... -'-----'•-•--------•-- ---
__.__.___'_______________________________________________________________________________________________...._.._....____'__________..._.___.__..__..._._..________._....____...__.._.._.....___________
Date
PermitNo......................................................... Issued........................................................
Date
' THE COMMONWEALTH OF MASSACHUSETTS x
BOARD OF HEALTH
IF. .............................. .. . .................
Trrtif irate of wompliaurr
THI 1 T ulA
That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ........... - -'- ---- .•••--'-••---•---••-
/ ! Instal
................................
has been installed in accordance with the provisions of Artic4thxI of The State Sanitary Code as described in the
application for Disposal`Works Construction Permit No--- --- . '. ........... dated....... .........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM,WILL, FUNCTION SATISFACTORY.,
DATE-------------- = ---•-• nSpector-•-•-••-'
„ ;THE COMMONWEALTH OF MASSACHUSETTS
v* BOARD HEALT
OF........
r
.
No.........- --•• FEE........................
�ttl � �trttrtin$t- rrntit
Pexmts'sion I he eh'`g anted- ----- ---- --------- --- •....................'----------._...•--
to Const'TUC_Lef or Repair ( n Indiv 1 S ge t o�al em
at No. '�i Jfl{ w + e::r `"�- / etf' t -
df. .
as shown on the application for Disposal Works Construction P t No ited
__._..-•--_. ;
' Board of Health-,,", x ~
--------------
DATE
FORM 1255 HOBBS & WARREN. INC.,.—PUBLISHERS - ..
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it.1s('�tJ,tr�EW;' SuQVEY j Tt-tE oFG'5ir=TS ei4owL-r> APPLI C 1-4j'r
tQoT es usc-o To Dcr =zM,NE-. LOT t.,.l WeS At_Ja A4A L .
LOCATION SEWAGE PERMIT NO..
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INSTALLER'S NAME & ADDRESS
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B UllDE R OR OWNER
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DATE . PERMIT ISIU E D
DATE COMPLIANCE ISSUED 7_1,c-- '-77
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