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LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME i ADDRESS
BUILDER OR OWN ` '
Cr�"�2C 7y�J JA7'.?.
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
AFP.QpX. LOG . OF
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$.M. ToP 4'fDMANT oPPoSiTE --540zE 2 iSTE2 !-d �'� �,�f?�/=` Or?
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct (___)�,Or Repair an Individual Sewage Disposal.
Sys tem at:
Add
ne
n!ta
Type of Building Size Lotgl�nj -Sq. feet
Dwelling—No. of Bedrooms...
Seepage Pit Nc
-0------------g me --------- Depth below inlet-----------_------- Total leachii f t.
Other Distributi Dosing tano(
Percolation Test Results Performed by..........
----------W7 _
p. ----------------'-----------
'-'-----.
0 eacr�too Soil -.�---_---'__-------------------'-�-''�'----''.----_--' ---'--'--'
----_-__---__---------_-----'-'---_--_.--.-------_.__--_'_-------.---- -:---
------------------------_---.-_-_-_--..-_''--''---_'--'_-'---''_---.-'--'--
�
U Nature o6D iorAtcradooa—Answer when uyp�cob��-------------_-_-.--------- ----
����������'������������'������_�����������������__���.�_�_��'--------------------------------------
Agreement:
----
The agrees to install the uforo600cr�ed Individual Sewage Disposal System in accordance with
the � ��� %I � � S� S�� C The undersigned � mn� � �� �
operation until a Certificate of Compliance has been is by the board of health.
Date
e is
en b
-'--''_-'--.--_----.
�Zn
--5
--------------
Application Apycvvcu By ^! � = � Date
�
�
Application Disapproved for the following reasons:----'--_'---- - ,--_.-.---�-----'-_.--_
---'--------------------'---'--------------------'----- ' --
�
Z Date
|| Permit No.........................................................
�r- - ,te
�
---------------'------------'------'- --'-' --' - -- -' - ----' -
IL
No..... ..q�l...... Fizz 4),...CK�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ajup iration -for Dispofitt1 Workfi Tonfitrnrtinn Vrrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
..... ?....................... ...................... ....................................
ocation-, ddress ' or Lot No.
' - ''� .r•--------------------------- ----•-----------•_......---•••..... ---••-•-• ...............................................
t Owner I j ,��yy pw.(! Address
trA� .__.._._._
V T.
Inrt3tde v Address r
Q -�..-j Type of Building Size Lot -_-- ..__�......Sq. feet
U
I-, Dwelling—No. of Bedrooms............. _..._..._.._._.--------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Ga
W Desi n Flow_-_-Other--- fixtures __--_�_I fI g111ons per person per day. Total daily flow.....................................:......gallons.
WSeptic Tank Liquid capacitAf_ .gallons Length__________ Width- .... Diameter----- ---------- Depth----------------
Disposal Trench—No ....,. < Width-------------------- Total Length_-____-_ _--. Total leaching area , ._ _____.sq. ft.
� Seepage Pit No,.���:--•_�_ iameter""'�_______,,__________ Depth below inlet.................... Total leaching ire3_, �___sc� ft.
z Other Distribution box ( Dosing to (
a
Percolation Test Results Performed by----- Q'.a.f' ite- izt,5......- �CAJAc%ate- ...-- '
Test Pit No. I................minutes per inch Depth of Test Pit_._________________. Depth to ground water. -
1:14 Test Pit No. 2----------------minutes per inch Depth of Test Pit....................,Depth to groun *at .___ �'I.____ _------ ------ ---- ------------------------------------------------------ --- � oc -� - '��`� ---
Descriptionof Soil---- ------------------------•-----------------------------------------------------------------------------------------------------------------------------------------
x
U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 Article XI of the State Sanitary Code,.lr The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signe - ��` -- n', r` _•-•-•-...._.. .._
0 r t+ ° ref -
Application Approved By....
* :. '1 - ---------- ---- -- ----- ---------
Date
Application Disapproved for the following reasons:...........•.....F.... .........._.V .......................____________._._.._ D
------------------------ ---------------------------------------------------- --------------- -------------------`-- ------------------------------------------------------------------•-••-. --
Date
PermitNo......................................................... Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ :� �t ............OF... ,ul ✓ : r :*Vt...:............................
Trntifiratr of fuIomplianrr
TITS IS, TO C)E-R-�IFY, That the Individtla'l Sewage Disposal System constructed ( or Repaired ( )
by r r IInstaller
atr . f- '' _ _f`t_CYk , .�s,- _ . d----- -t.; A S. f .
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No-------- ................. dated...._., . 1- ._..._._._...._....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector...................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARDt OF HEALTH
e..is ky
e3 f
1
rl P,t?A).. .....OF.:. t .{ ....:t..` .... ......... _, r 1
>'._...--_.. FEE.-:...•-� � s
�i��o�' 1 or�,����on�trnrtinn rrmit
Permission i ereby granted_ �_._f'_, e__. :��_ _ __.. %�-- — -
ri t --- ---- -••-••-•----•----
to Constr ct ) or Repair ( «)an Individual Sewage Disposal yste .�
<<. -_ ------------------
_Street
as shown on the a lication for Dis osal Works Construction erfinit No �- ated= _________________
PP P . ` -=.
------ ---------- ------t.
------ `
4 Board of Health
DATE.--- ! ' - -----------------------------------
FORM 1255 HOBBS,r& WARREN. INC.. PUBLISHERS