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LOC&.TION : 5EW66C�E PERMIT 100.
VILLAGE
IWS-TNLLER'S 1 &ME ADDRESS
Ct
BUILDER 5 ADDRESS
DD,`TE PERWT ISSUED
D s.TE _COMPLI &MCE ISSUED :
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No......................... ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�Ztlh-c. .............
Apphratinit -fur Disputitt1 Works Tomitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair �anlndividual Sewage Disposal
System at:
....................... ••---- /GG •-..---------------------.......--•-----
Location-Address or Lot No.
FLG --------------------------•----•--------•-•.......... ------.................•--
Owner / ddressf-
a .CSr,. ........ = �"� �e�....J7... ....1� /r ITZe�1. ..------
Installer Address
d 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`2 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 "lest Pit..............--.--. Depth to ground water........................
C14 Test Pit No. 2................minutes per inch Depth of Test Pit.....---............ Depth to ground water..........--------------
a --•---------------------------------------------------•-....................................................................................................
0 Description of Soil. `xA
U
W
U Nature of Repairs gx,,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 furthe agrees not to place the system in
operation until a Certificate of Compliance has
been issued by t e oard ofheal kI.
( 1'�� l (c
Signed.� ----------------
Date
ApplicationApproved By.................................................-----------------------------....----•-•----•--
Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------- --------
Date
PermitNo......................................................... Issued........................................................
Date
rT
-------------
THE COMMONWEALTH OF MASSACHUSFTTS
BOARD OF HEALTH
flak— - -------OF........1�'�/i:.�.�.��s..l.�. >z.a G.c- --
Applira#ioo -for �iopooal orkii Cnort #rortioYt rrntit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
..................... -----------------•--- --•---- .'"....................=...................................
Location-Address or Lot No.
d/7-ii/ li L G_ ....................................
owner Address
................./_f�--cam - ;��� � ! f7'----- •�a..-t......................
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------ ------------------------------ --_-------------------------_------
w Design Flow..............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic 'funk�—Liquid capacitv./ "4allons 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.-.-___--._..._--------.
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
04 --------------------------- ---------------------------------------------------•-------•-------_.__....-•---••-----.._---•-•-----••-------------•-•---------
O Description of Soil -------=-------------------------------------=-- ......7- 1 -
.� `.� __ _
w
U Nature of Repairs or Alterations—Answer when applicable.-.---- (yti L---- 7.l�.......
-•-------------•----------.-_----------------_.----••------------_.____--..--------•-----------•--------------------_----___-...
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_a rees not to place the system in
operation until a Certificate of Compliance has been issued by t e board of health.?
Signed_`rY> ���__ fl uK l c"" ,_,.�. 4 7
---•---- ---------- ------- -----------------------
Date
ApplicationApproved By............................................................................. •---•-•-•--•••-- ........................ ---------------
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
---------•-•-------------------•---•--------------------------••--••-----------------------••--------------------------------------- -----------------------••----••-------...........................
Date
PermitNo--------------------------------------------------------- Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................OF.............r��/1.Z!` .............................................
0.1rdifira#r of Tompliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( 4—
/, Instta11
at Z �-�/`! ` _zG-tn✓ '�A Y----/------G----------�--f!" --------------••-•----•-------•------••--•----•-------
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....(�_ -7................ dated-----G_':. '_7 ___--.------__-________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. T
DATE.......... ---------
Inspector.............. ------- - ----•----- --•--------•----------
THE COMMONWEALTH OF MASSACH TS
f BOARD OF HEALTH
..........�� 1.................OF......./ dy 1. 1 �.fa,I3.c.. :. ........................_.
No..-----••----�----� FEE--- `..
Bi-spatial Workii Q1ootitrorfion Vrrmit
Permission is hereby granted---------- -----.__-/?�-- -------------------•-----------•-------------•--_,___-------•---------•-----
to Construct ( ) or Repair ( 6—an- Individual Sewage Disposal System
at No... -----.�1.F? c•��L a��_...Dg--•----------- r� ��...................
Street
as shown on the application for Disposal Works Construction Per '1No._.___f' ____/Z/Dated------- _ 3_-. ..........
-------------�('_- � � �`` � -----------------------
---_
/ _ Board of Health 7
DATE-----a--.l�.. �.-�-�`-=------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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