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LOCATION SEWAGE PERMIT NO•
VILLAGE
INST' A LLER'S NAME i ADDRESS
v6 eS
I U I L D E R OR OWNER
DATE PERMIT ISSUED
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DAT E COMPLIANCE ISSUED _ jai
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
o ..............._0F............ ft ,us.7�`J �-4.------------.----•-------
Appliration for Di-4pori al Workii Tomlrurfinn Prrutit
Applicaflqn is hereby made for a Permit to Construct (M or Repair ( ) an Individual Sewage Disposal
y tem at
`��a----•-•---•---------• -•---•--•-----------••- � `37• - -
- L at n-Address or Lot No.
......•• ff v4 F ' �v�.1�)... .......................
/) Owner Address
a ••--._....-•- c L ................................... .... 'E,crr tz ._L [.c
Installer Address
.14 Type of Building Size S.�U 5�____Sq. feet
Dwelling—No. of Bedrooms_
______________.....................Expansion Attic ( ) Garbage Grinder ( )
'404 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures ________________________________
W Design Flow.............. ....................gallons per person per day. Total daily flow.........3�_ ......................gallons.
WSeptic Tank—Liquid capacity./2dP_gallons Length_____-9_!...... Width_____��__._`_.... Diameter________________ Depth____4.......
Disposal Trench—No_ ____________________ Width-_---------------- Total Length.................... Total leaching area.........._.........sq. ft.
Seepage Pit No........f.......... Diameter------e--------- Depth below inlet....... .......... Total leaching area_-!.!._....sq. ft.
Z Other Distribution box (x) Dosing tank ( )
Percolation Test Results Performed by....4'a?!eG E LoW __Go Date. __'__Z_"'_...................................
Test Pit No. I... ....minutes per inch Depth of Test Pit____l¢ _"__ Depth to ground water_V__01.._:..F�tl_-
Test Pit No. 2__:5 _Z__.minutes per inch Depth of Test Pit---M4l....... Depth to ground watera_aA/TEED
-------• - -------------
O r 2 o �t
Description of Soil.-4/ ------------------------------------��-----------���------�----------------��--�--'----
V •--••-•--•--••••---
W -------------------------------�-Z............. ..................------•----•---------------------------------------------------------------------------------------•-------
VNature 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'TT!.:
p5 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 the board of health.
igned _.._ ...... •- • --•-----•------•-•-•---•----•-•-----------•-_--••. ••••-•-----•----•...............
D
'A plication Approved By.-..— -----... "._.. _ _...._._
Date
Application Disapproved for the following reasons___________________________________________________________________
_________________________________________________________________________________________________________....________________________________...___✓___________________________..._ ___.___
Permit No......................................................... Issued_-- �_ .ate--_...
Date
No. .... ..__✓�� ..7 FAR.... ..............
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................O F.........................--------.....
Alip iratinn for Bhip r i ai 10orkg Tnnitrnrtinn Urrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
�a 7 3 7
.................................................................................................. •-------••--•--------••-...••----...._....•----------•-----------•-------•------------••--••--•••-
Location-Address or Lot No.
�Er� F-:...:............ !.!�1..... _GTT LN__�a 11.9.e-v!-.....--- " -a...........................
Owner Address
W �R ................�__ .... ddres............. /
Installer As
Type of Building Size Lot.t5-T.L$D.�---_..Sq. feet
Dwelling—No. of Bedrooms...........3..._.._.•....._.•...__..__..Expansion Attic ( ) Garbage Grinder ( )
p:14 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures _________________________________ _
W Design Flow................5�.................gallons per person per day. Total daily flow.............................. ................gallons.
WSeptic Tank—Liquid capacityl6 U6_.gallons Length-------g`.. Width....... '_. Diameter________________ Depth.._¢_'.....
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-_____-----_--_-•-sq. ft.
Seepage Pit No........I.......... Diameter........6....... Depth below inlet.._....._....... Total leaching area...Z�Ro......sq. ft.
Z Other Distribution box (,V—) Dosing tank (` )
a Percolation Test Results Performed by........................................................................ .........
Test Pit No. I_. .Z ___minutes per inch Depth of Test Pit---- .`._ Depth to ground waterA.;.sT.._E __-
(i Test Pit No. 2-.•-<.;L.minutes per inch Depth of Test Pit---l9_5f__'-.. Depth to ground water.9o0ti���A
W ...................................................................................................
O Description of Soil-,---•---nr...�-�,, .,.....................................................rs5oi.. 7 ="--$'-- .......
GIJ----------------------------------------------------------
G`.�/--
W _ </9i"7�
- ----------------- - ---------------------- - ........................................................... --------•-------------------------------------------------------------------•--
U Nature of Repairs or Alterations—Answer when applicable-------------------------_----------------------------------------------------------------------
--------------------------------------------------------------------------=------------------------------------------------------------------------------------------------------------------••-•.----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
f'iT
the provisions of _1 f1'"'E 5 of the State Sanitary Code..—ITWU'ndersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
igned ---------------------------••-•-......---•
Y ...........
Application Approved BY --- W. -------•--------- j�
D
Date
Application Disapproved for the following reasons:---•------------•--------------------------------•----....-------•--------------------••--••••----••...-•-.-----
_.._�
Date
PermitNo. ------------------------• Issued-..-----•---•--------------------------------..1. .
Date
4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 3 Olf HEALT
......... �' . ..........OF..... ... '.........
Olertif irFa#r of Tuniplianrr
THI IS T CE I That the Individual Sewage Disposal System constructed (/or Repaired ( )
by : . +• .- ------------------------ -- ---•••..._...... ------------------•---
_ _______________________•-_--•- -•••.••--------R
Install
at ----------- ----------------------
has been installed in accordance witlithe provisions of j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N .._..., " ...�7.'___-•_-_. da.ted___..'�''w 4_t�-_ ..................
THE ISSUANCE OF THIS CERTIFICATE SHA L NOT BE CONSTRUED AS k-,E UARANTEE THAT THE
SYSTEM WILL F)15CTION SATIRY.
DATI? 7 '_./ ...... -- Inspector... .. --- ----- .........................................
_..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OE HEALTH
... ................O F..,.-----..Z.,.4�................................................
FE 4�......-•-......
permission- s h.reby granted....... ._.. .....t.. ---------------------------------------------•------------------•--•---------
„
to Constr ct or Repair nd' idual Sever Dlspos / st
at No.
t3l1 '' + :� 'AkO �r "` Ace• =. �1`+ if- 'l..'.._
sty. t te�rr}}
as shown on the application for Disposal �fiTor s Construction P r N*;/ ._____ ; ated.._�`_ `' fir'.............
�' -•---------
Board o Health
DATE...................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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