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LO AT ION V7W&e
\SEWAGE PERMIT NO.
�,
v L L A G Efout� ' �a3oZ/'f o op
INSTA LE 'S NA E It— ADDRESS
B U�11)E/R� OR OWNER
DATE PERMIT ISSUED �-
DATE COMPLIANCE ISSUED � �
�� '' �y�'
/ f- � /, - -�..
r
-No 84\ "
THE COMMONWEALTH OF MASSACHUSETTS ..
BOAR® OF HEALTH
i.....................OF.... r. .� ,�1. , :............ ...------------------
App iration for Uigpniia1 Works Tumtrurtuan Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: oo /f�
- ...........�XZ 1,,�.nl r ...� sler.._...5�.�1�t --------•- ---------------------------------------------------------jo&.. ........
Locatio -Address ! or�L-ot No.
................ � 1 f.P�-.. . -.e2-ram'--------------------.- ------.............ioe&* ��ief �€'.. f� ..................---
Owner _ Address
,.� -----_-------- .......................... .............•----•-•------.....-•-•------.................
Installer Address
Type of Building Size Lot___ j_0'7-......Sq. feet
U Dwelling—No. of Bedrooms___ �t�+- ...................Expansion Attic ( ) Garbage Grinder 0-)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ......................................................................................................................................................
Design Flow......................... .•S____......gallons per person per day. Total daily flow---- ,YO..64P,,, ........gallons.
WSeptic Tank—Liquid capacity , gallons Length................ Width................ Diameter...-............. Depth................
x Disposal Trench—No..................... Widt ----------------- Total Length.....-_.. ._....... Total leaching area....................sq. ft.
Seepage Pit No.__Jft ____ Diameter-__- ......... Depth below inlet... .......... Total leaching area.2.0/-----sq. ft.
Other Distribution box 4,- ' Dosing tank ( )
z Percolation Test Results Performed -- .. . _ ...................... Date_.:_�a__-6. �'-'-.......
a Test Pit No. 1......fV._._.minutes per inch Depth of Test Pit--------1...._...... Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' ------ .............._....
"�
Description of Soil : = ----..------------ `,
U -----------------------------•-•----•--•---.---•----•-------------------------------
W ----•------•-•----------------- --------•----------------- -----------------------...------------------•----....... ------------------------------...-•--------•-•-----.....-------•-------------------
UNature of Repairs-or Alterations—Answer when applicable._--............................................................................................
--•-------------------------•---.........-•--------•----------------------------------------------------•-------------------------------------•----------------------------••-••----....._......._..--•-
Agreement:
The undersigned agrees to install the aforedeseribed Individual Sewage Disposal System in accordance with
the provisions of iI1:LE 5 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.
f
---XZZ4; ..................... .... 7
Date
Application Approved By------. f.... ----- .-� ..-....................... .......Dal .
te
Application Disapproved for the following reasons----------------•-
...............................................................................................................••-•---•-------•--•-•-------•---------•-------------•-----•---•-....--------------------
•--.Date
Permit No......................................................... ' Issued.....
Date
i,
k. .
No..- ..Q......._ Fzcs.. ... .....................
THE COMMONWEALTH OF MASSACHUSETTS
._BOARD OF HEALTH
I,. /-
Applirttfion for Dhip ,gal Worki Tonotrurtinn jkrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
...............f -dG.�' :!i:. l .l.?.... .�F.�'t ....&V ---------- __-•-.....__ ........................_....__...:_---... .. .----__.
♦i,.#�+ . ,/s Locatio'� -
Add re� or Lot No.
.....-........ "... ! .d: .. ..f•f,►�f �f!t=" ...........I............... .•----.....---.._.__._..... l r,, e�15:d --•-Y�i* d`tEW ...............
e[ _r Owner _ Address
` T Installer Address
Type of Building Size Lot___ _�:74.__._.Sq. feet
Dwelling—No. of Bedrooms.-_ . -:._ __.________•___..__Expansion Attic ( ) Garbage Grinder ,)
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
P4 Other fixtures . :..
W Design Flow......................... ____gallons per person per day. Total daily flow--------- .......
Septic Tank—Liquid capac>ty/.,r3' gallons lLength................ Width................ Diameter_.____................ Depth................
W Disposal Trench—No..............f----- Widt ................... Total Length____.____ _____.___ Total leaching area______________._____sq. ft.
Seepage Pit NO... ..... Diameter____........ Depth below inlet-_ __________ Total leaching area., ',�_._._sq. ft.
Z Other Distribution box4 ) Dosing tank ( )
Percolation Test Results Performed by.__ >-��- __ _., ___ ___________________ Date__ a_"",� 4
,.� Test Pit No. I.....&-04..-._____minutes per inch ..Depth of Test Pit.......l.:2___.___ Depth to ground water........................
Test Pit No: 2................minutes per inch Del3th of Test Pit.............. ._. Depth to ground water........................
•'
_
O Description of Soil------ ...............p�l"� •... ��`-"--- --- � ...-------
.......................--- ---•----•-- .
U ............................................................-•---------•------••-----•---••..._..----•----------------------------•--.._....--••••--•-•-----•----•----•-•---•-----••-•-•--------.._...
W ;.
x Nature of Repairs or Alterations—Answer when applicable__
U P - t
b
..................................................................................................................................... ............................................................
Agreement: �€
The undersigned,agrees to install the n oredescribed Individual Sewage Disposal System in accordance with
the'provisions of TITIE 5 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.
N
S.
Date
Application Approved By....
------
Date
Application Disapproved for the following,reasons:-------•••------•-••-----------------------------•••-----•------••-••---........------•---•-----•-•--...........
............................................................ . ........." ------. .----• --------------...----------------------•---------------•- -------------------------
Date
Permit No...... .. Issued -------- - '
-• .. ................. Date
tr THE COMOONWEALTH OF MASSACHUSETTS '
'
l
BOARD OF HEALTH
`. wY1......O F.... X
gotifiratr of Tomplianu
THIS ,` •O- 1)3R t the Individual Sewage Disposal System constructed `( or Repaired---------------------
( )
} Installer s
df ..
: . / ..
'has been installed.in accordance with the provisions of`TITZ!-? > of The tate Sanitary Code as described m the
r ,. ` dated_-7",?.4%. --•--•--
appiication for Disposal Works Construction Perml � ___ ____ T- EJ ........ t
THE,ISSUANCE OF THIS CERTIFICATE„,5HALL NOT BE CONSTRUED AS A GUM ANTES•THAT THE
SYSTEM WILL FU CTION SATISFAAC RY
u ;DATE:: > " - Inspector^•:t.: <.: .. ..;: ';�<L�.. ,.. ,• ��_-_•
THE COMMONWEALTH OF MASSACHUSETTS
r BOARDC7
HEALTH
q ' ............®F'....:.. FEE
No.......................... .. .........
Disposal rkn_ rrtt$
Per Thereby rante .."...�' ..
...... .... ..... ..
to Const or a air �)»,an^Ind' idual S e Disposal S '
atNo.- l s.... . i, ".." a •;F -------- ..... .........
J1 + Street
Y as shown on the application for Disposal Works Construction P No.__ t.__ _ Dated.__ ..........
f... . ;.� .... ..................
`�,l�
. Board of Health �^:
DATE... ..:.d:" . '
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
,r+-�.F�„_ -�...`---i"'- -" - _ -. - mot` _"' -•�
St�tG:t..� �:AMtL�! - 3 �3®sz�a•vt � �•t '
►..lv GAtzs�i~ U211..tG��.tC
T�.d t�.�( F Low = l i O � 3 t 33b G.P•b• r:. .
330,t ISO % = 4595 6-P.D.
USA- t oc>o, C=A L..
77I'SPOSAtr PIT usE t000 mat✓ i r9 c �Ko�:
-- SUGU A.LL AtZ A = tSo S.i=. o
t� sF 2.S = 3"7S G.P.D. i { �'�•..�v
TOTAL �ESIGt�I = 425
TOTAL 'C>at L.-4
Plr-fZGDL&T%C> l 2&TE j"tQ SM l Q' o2 LIrsS.
• '�---�.,._. Y -�,s,�,r�ram.
TsT fo'IG!7 g G. F�oo Top i✓Uu =
IOaC> IIJV.
I
S!/8 50rG Dist. W G ol. 9G.74
'box
IWV. TiawK
000
GAL. 9 .95 9E✓ ,
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AL.1t> SC-.'TC3ACIC
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