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"MMEMEMENEEN
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LOCATION SEWAGE PERMIT NO.
ty`,5- 1,2Kvla/L l go 1
VILLAGE
C �/ c�Let
I N S T A L L E 'S N ME & ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
`�,- �`
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No......l :.. F �`a'......
THE COMMONWEAL,.Tki OF MASSACHUSETTS
BOAR® OF HEALTH
�tJ...................OF..........., ..�t-
ApplirFa#ion for Uhipoii al Workii C on.6trurtion lbrmit
Application is hereby made for a Permit to Construct X or Repair ( } an Individual Sewage Disposal
System at
.....�. J` ..;� .`1.��/.�1. .`-s '-�--- --------------- .. - - ....................................................
Locati n-/d dress or Lot No.
...... ..f.. ...1J.C... � �.GE!�j.�.._...ei:�,'E�---•---.... .---�:.�ra.�,?.,/_e .fh�............................
Ow er C Address
a ✓-•E .1: ��f"f�. ............................. ........... 442, . .. i�t'� ..........................................
Installer AddressPQ
0�
d Type of Building ---- --�� Size Lot_.._�_Z ?'.__..Sq. feet
U Dwelling—No. of Bedrooms.........7a.1. .......................Expansion Attic ( ) Garbage Grinder ( )
p`-, Other—Type of Building ........................... No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures .. .............................................................
W Design Flow..........................tC&. __.....gallons per person per day. Total daily flow.._....._3 e...................gallons.
1:4Septic Tank—Liquid capacity.l v_..gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No. .................... Width.................... Total Length.._.._.__........... Total leaching area....................sq. ft.
Seepage Pit No...i ..... Diameter____________________ Depth Belo in et........_........ Total leaching area..................sq. ft.
z Other Distribution box ( Dosin a ( d �� (s��e- 7aC
Percolation Test Results Performed by. . .�---:.-_L,aG_... Date_._" _`.lC.` .._..
W
Test Pit No. 1................minutes per inch .De i of Test Pit__.._.._._._..._.__. Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of iTest Pit.................... Depth to ground,water._._................___.
--------•----------------------------------•----------......------------.....---•-----------•----------•-------.---.•-.----------•-----•-- -•------•----
o Description of Soil........va fer;g<.••••��r ------------------------------------
x
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 TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue y the board of health.
S• ed......
----------------- ---��: ._..
31��� �� Date
Application Approved BY----• -- --------- - �..�,��a%�.�..._...-•----•---------•--- ------- --..'?`S'-:��........
Application Disapproved for the following reasons---------------------=-------------------------------------------------- -----Dace--------------
................................•••-•-•-•--•-•••---•••--•••-•-----••----........•-••----•--•----•--•--•-.-----•--•••---••--------••-------•-•---•-•••--•-•-•---••••-•-------------•-•••----••--•-•--•-•-
Date
PermitNo......................................................... Issued.......................................................
Date
r w --
THE COMMONX4LEALI-1 OF MASSACHUSETTS
BOARD OF HEALTH
. Tol............ .....OF...........A,�`".�i�!`+ 44A.:............
"
Applirtation for Dispooal Works Tonstraartion rrnait :
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at
Z ...... AM&Ai . ..................................................
Locati des's or Lot No.
�... r., 2'1t X, ; ,!/ ,a.�......._.... - ".--._ E- .�1, .............................
r ;. Address
W •. •-•• ,��+ff e
�•> _ -. '�.� ,�"...............................•^..... #Otw . sl !.....-----._.....---
a
Installer Address
Q Type of Building Size Lot.__+� Sq. feet
:...
aDwelling—No. of Bedrooms---------- i'9_____________________Expansion Attic ( ) GarLageGrinder ( )
p, Other—Type of Building .............................. No. of persons............................ Showers ( ) —Cafeteria ( )
a' Other fixtures ...........................................
< ----------------- -------•-------------------•--•-----------•- _....•••••••-•--
W Design Flow.......................... per person per day. Total daily flow......... _, �_______c:__________gallons.
1:4 Septic Tank—Liquid capacity., __g g !"_'� p allons Length Width._.`,:_._._.... Diameter;_._;.•._.____.. De th.................
W Disposal Trench—No_ ____________________ Width......... Total Length.._._.__.__...__.___ Total leaching area...............:_:__sq. ft.
x ,
Seepage Pit No.__1IsW0..... Diameter____________________ Depth belo )einlet.. Total leaching area__................sq. ft.
Z Other Distribution box (jef Dos in a
'-' Percblation Test Results Performed by. �z'�.............. !��,� `;;✓_____._.____ Date._ _ ..._..
Test Pit No: l................minutes per inch Depth of Test Pit___.________..._..__ Depth'to ground water..........................
44 Test Pit No. 2........._......minutes per inch Depth of Test Pit----:............... Depth to ground water........................
••-• -----------------•-•-.._.........•-•••-----
-----•-----------•----•---------------------•-----•-•--
D Description of Soiltsc, ., . ----------------••--•-._...--•••-••---••---
x
V ....•---•••--••-••••••.._._.....••••••.......-•-........•-•--•--------------•-••--•------._...-••••-...........
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue.. `.y the board of health.
Snd .............•---ie � ._. ;
Application Approved By....
Date v
Application Disapproved for the following reasons-------------------•-------------------------------------------•-•----- ................................... .: , , •.
a,
---•.........................•---•----•--------------------------------------------------...-----•---...-------•••-••-•••••------••---•--•-•••-••---------------•--------•-------•••...................
Date
PermitNo......................................................... Issued......................................................
Date
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r ........ .................'�............0 F......... .a_.V'k.l.....:...............................................
(Inrfifirttte of Tonaplianrr .
TH/r IT TO..•ER I Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-•r- rf_''-'-............_, ... ................r.............................. ^ --.......-
- --
° �y nstaller f
has been installed in*accordance with the pr 4sions of j of The State Sanitary Code as described in the
<
application for Disposal Works Construction Permit No.__--- _. _ ;s ....... _______________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
"DATE................................................................................ Inspector.....---......------------------...................................................
y
THE COMMONWEALTH OF MASSACHUSETTS
r
r
BOARD O HEALTH
��' �..........0F..-.....' /lG!�!Y!.................................................... ��
No.........................
Disposal, 9.W i�an permit
Permission is herebyranted �.�!� �`. ..
to Cons ruct (�ar`) pair ( ) an I dividuaf�e age Disposal Syst
at No. - :_ . _.1����!. �1.-r_..... 5......y���'z�a ..�1. �' ............... .................................................... .
Street _
as shown on the application for Disposal Works Construction Permit N r� Dated------ ...._.......f...............
Board of He `
DATE.................................................................................
FORM 1255 HOBBS a WARREN. INC.. PUBLISHERS aJ
� t S`. _ r •. t..,._ ._. — _.a....:,,. :.. .. .. ..Yv_... .. r Ie,F&Ltl-v�I' Y3�"Riy`�.
!SZ
t��! F'tAw ►to ►c 3 = 33t� �•PD. PirrP'
SE tG T�1►C = 330,e 150 % • 4-95&P-D1
DISPOSAL PIT - L-)SE l000 G�.'.Z� i ;'
TOTQt_ `PESt6W = 425 G.RD.
ToTA t_ r->Ad1 FLOW z 330&F.M.
PT-=gCDL.&TxoQ 216TE : C IQ 2•Mt U•o¢ LT--%.
//Q o-• t ` I� � S" I _ 31 ��, i
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6. 77,0 4 � .
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