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LOCATION - _ SEW&C1E PERMIT_ V-JO.
- II�ISTQLLERS dt�/lE � AD-DRESS. _ _j
- _ BUILDER 5 -tJ-/ MF— -ADDRESS
_. DQTE PERMIT
.— DATE COMPLIW 4CE.
.�
.,-
���
�-'� -�
.h ,�-, � _�_ -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF 'HEA-LTH
-- --- ------U, .. ...................
Application is hereby made for a Permit to Construct or Repair �_) an Individual Sewage Disposal
System at:
---4. 7. P A
Location Addre s or Lot No.
L4 Ow r. Address
. ........4
�
Other Distribution box Dosing tank
4h ,,n --------------
U N t epalLs 0 0 f
/., 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 agrees not to place the system in
operation until a Certificate of Compliance has beeq issued by the boar o alth.
141 Date
. Application '' By ' ~ ' - ---------- —r'~'......
0��---- '
Application Disapproved for Me following reasons:............................
---------------------------- -----------------------------------
---------------- --------------- —.'------------------------- ------- .--'-- __-
V Date—
� Permit No.............................................. ......... Iuoo�d-'^���-�������.-'.....'...-.....-----
»"te
`
--`-----------------------'
No......
Fmic............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/.....� ......_----OF........... Gl - 17..^...
Appliratiun -fur 13iipuuttl Workii Tomitritrtiun Vane t
Application is hereby made for a Permit to Construct ( ) or Repair ( )) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
•----•'•'•' ✓•I--------•-----.......------- .......................................... ..............................................-•••---'•-••-"'--••'-----------..__.._..........---
ow _ n Address
Ir9taller Address
Q 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------------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 "Pest Pit.................... Depth to ground water-......-.--.--. -.---.-.
(� Test Pit No. 2................minutes per inch Depth of Test Pit.--__-__-___.___-_-- Depth to ground water.....................
----------------------- ------------------------•-------------------------------•----------•-------•---•------------•---•-••--------------------------_.---
ODescription of Soil--------------------------------------------------------------------------------------------------------------------------------------------------------------------
x
U
--------------------- ---------•------------------ = 'i
N ture of Ze sirs or lterat' ns—Answer whe hcable._��_✓� -- / 0 O
U P` P• ---- -------------•-------
� - - ----------------- -----
greement:
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 agrees not to place the system in
operation until a Certificate of Compliance has b9M issued by the board of .ealtli.
gned
Date _
Application Approved BY•--- --_ ----. ,�.
1 ._ ....--•---. �-�- lS�------7-A
Date
Application Disapproved for the following reasons: •---•-•-------•--•-----------------------•--•-••--•------------•--•-••--••.---•-
...................-------------- --- .......................................__......................................................................................................................
J / Date
Permit No--------------------------------------------------------- Issued....G - l Z-.-......------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
.........OF............... ""T"'......
101.1rrtif iratr of TlImpliaurr
THI O C TI That t e Indi ual Sewage Disposal System constructed ( ) or Repaired
bY-
G
Installer
has been installed in accordance with the provisions of Ar?'M XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--- y --------•--- dated- -- �-- ..�.1 7 j
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE_`. �.`_. Inspector---- may. •••••. /�A
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
�GG ........OF.............. .......---
No.-----•---•-••--• FEE---- ..................
�i��>Qutti urk,� unu � rtiva "__
Permission is hereby granted ------ ---- -- ------ - - ----------------------------------------------
to Construct ( ) o pair ( � ndividual ewage Di l S
at /.. _
Street /�
as shown on the application for Disposal Works Construction Per d...........
11' -----------------------
Board of Health
DATE..../�.........................................------------------
Lam—
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS