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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................O F................................_...........---------------..........------..............
Appliration for Diopoottl Workii Tonotrnrtion Vami#
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:
]5 Cn.... r'S 1.1a1 2...I...... .... ....... .P.7--.....L.!........
Location-Address or Lot No.
..1�,! 1I1 � �.! ......,=.�^.�.e,c...... ......... ....&j k..--..T21.---._.�...71., :t 1.e .c 7,4.......
Owner Address
........�.0.5...... ...................... ......•-•---------•----.......................------•-----.....---................-------•----....
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.................... ...'.?Q...........gallons per person per day. Total daily flow--------------- ..........gallons.
c4 Septic Tank—Liquid capacity.M.O.gallons Length................ Width_............. Diameter__._...,........ Depth................
Disposal Trench—No._.�................ Width..l.�.......... Total Length..Z-..(y/..... Total leaching area.:_ ___._.. .....sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area 2 sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date....................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minute's per inch Depth of Test Pit.................... Depth to ground water........................
----------------------------------
•----------------------
--..........................................................................................
0 Description of Soil..............................................................................................---------------------...---------------------------------•-••------------
x
V ...............................................•-----•------•--•.....................------------.......-------------•--•--••--------------•----•----•....••----------------•-------••------------------•
W
-------------------------------------------------------------------------------------------------•---•--------------------•-----•-----------•---•----•--••••--------••---------.....--•---•-------------
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 iITI L 5 of the State Sanitar Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has a issued by the board of health.
ID
{
Application Approved By--•-•-•.-- . ..... .:....-•------------------....................................... . ...
Date ......
Application Disapproved f o h ollowing reasons:................................. .
....................................................... ------------...------------------......------....._...........-------------••------•-----•--------------....----------••......------.........._..
Date
PermitNo......................................................... Issued_.......................................................
Date
040-T /6 Y6
LO CA2 ION SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME i ADDRESS
SUILDER OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED Ifl
13
a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
Location'-'�-jWr-ess or Lot No
Owner Address
Installer Address
Z- Other Distribution box ( ) Dosing tank ( )
-.-----_'.._-_-.-.'--_...--..------_'-_'__._'---_-.—'.---'-----_.--.-----.'-''-_'_____--
Agrermeot:
The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
the provisions of TIT 1Z- 5 n6d the system in
operation '
liance has .'ee� issued by the board of health.
------'-- ------
��,"-_-,-`� Approved -'--. __--_-____-__--_-------'----'-- -------'�'-'���-------
Application Disapproved fo ollowing
rxu^omx:.-------.--------------.-------.-_------_-'`--'--------
----------'--'----'--'--'-------''----'-----'-------------------''-----'----------'-----------
' Date
Permit -
Date
/
!
, r*E .CoMMowvvsuLTnoF MAssAoHussrrs
BOARD OF HEA t' ' '
�
.........................................K�F.--_---_.........................................................
TH1_ 4" Trrfifiratr of Tompliatta
ERTIFY That t e In ividual Sewage Disposal System constructed or R'epaired
by
staller
has been installed in accordance with the rovisions 0' TITLE- 5 of The State Sanitary Codpellis jxscu*bed in the
THE ISSU NICE FITHIS CEkTIFICATE SHALL NOT BE /
SYSTEM WIL ION SATISFACTORY.
'~~^^^^-`r -^--'-------------------- ^~~p`�"" -'--------------'--'-'--'--'-----
rHs oomMowvvsAcrx or mAseAo*ussrrs
� BOARD OF HEALTH
..................................���.��F���������������__���������
N°=-^`—^'---- FEE
as shown dn th lication for Disposal Works Constructi Permit/ ....:,,,.e.-:-:yAated.4�� -------f
Permission is bAfeby granted.....
�^ .......
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