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FE M E A D
KEEPING YOU ORGANIZED
No. 12534
2-153LOR
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INITIATIVE CONTENT10%;V
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LOCATIOPI SEWACE PERMIT NO.
VILLA_ CE -
INSTALLER'S NAME ° i ADDRESS
Coe
B UILDE.R OR OWNER
Cam- 4 ,Lr�s s-
DATE PERMIT ISSUED
DATE COIMPLIANCE ISSUED J� ��
�eA2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD-OF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Svstem at:
Owner Addre�ss
Installer Address
Type of Building Size Lot...../1-is... 4t" Sq. feet
Z Other Distribution box ( ) : Dosing tank ( )
--__-----__--_. —___—.- ' �
. � -^�- _^
^**^^.e.`.. ^ -~=
� The undersigned agrees to install the�-df6redescribed
' - � ^
THE COMMONWEALTH OF MASSACHUSETTS
3j= BOARD OF HEALTH
........
...........
.".....................O F.........................................................................................
Appliration for Disposal Works Tonstrurtion Pumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
--•-•-•••-••-•---............................................•------------•-•••••................ -•-•--••--••••••---•-•••••••-••••••-••-•••••••••--•-•-.........................----.........••••-•
Location-Address or Lot No.
Owner Address
W
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QI 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---------------------------------------------------•-----.....-•---•----.•.............-•---............------••-------•--------...........-•-••••••---.•..--
0 Description of Soil........................................................................................................................................................................
x
V -----------------------------
---------------------------------------
-.---..---------
------------------------------------------- ---------------------------------------
UW -•-•-------•------•-•-•••. -•------•••••-----••----••--•••----------•---------------•-•-•--•---•••-----------•-------------------------•-----•-----......••--•--•••-••--•-•......------........----•..--
Nature 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 Ti:'f,l. 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.
Signed-------------------------------------------------------------------------------------- .... •• "e
- i -
Application Approved By1forZe
.
DateApplication Disapprove following reasons-------------------------------------------------------------------------------------------- a.-......--------
....-----••----------•-•-----•----•-•--•••------••---••-----•..................•-•--•-•-•..........•---•-I--------•--•-•--•-•----•-••--••••-•-•-•-----------------------••-•••••--••-----•--•--......----
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................................OF...................:.................................................................
(In ifiratr of Toutplianrr
THUS CARTIFY, That the Individual Sewage Disposal System constructed orRepaired ( )
by..- •• ----
:..
Ins el
�.
at. ----• _..._... ..... :_ � ------------
has been installed in accordance with the provisions of TI�'�L•E 5 The State SanitaryCode,'KS d cribed in the
application for Disposal Works Construction Permit No----d. __�__ k '.............. da.ted , fl__...;.' ._______ __._._._.._._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................•----•-----••-------•---•---••-•--•--•--•---•-_. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR F�
(J� r ......
... rF.aF S.....................OF........ fi� .... ..................._.... ss"'
No.......... ........ FEE-•--•- :5•••-.....•••-
t Diopo�mi�l// ork ion #iort rani
Permission is hereby grant L!_ �
to Constructor epai �,.) an diwrd� Sew Di { Sal System
.at No.. !'.. . . ---- --......_. �! h�" ��e
z.............- ------------------- ----- -
Street fe as shown on the application for Disposal Works Construction Permit No,._...___ ___ a ed..... ..... ........................
.................
............•-• IZ-------------------------------.--.-------------------------•--
...................................................... O Board of Health
FORM 1255- HOBBS & WARREN. INC.. PUBLISHERS
SIwGLE FAMILY - "15 Bmoszoo/H
r�
1.1.tJ-G,ARBAGE GQ.I1JDEsR.
►I.Y _F L_caw s I I O x 3 = a3 o G.P R AN C o V,/I-A vh
5EPTI6' TANK = 330XI59>% 3- 491;G.P. o 20,dT_,)
usE l000 6A1...
DLSPoSAL PIT V4E tyo0 GAL. �S ,-I.,
5 I DaWPI.0 AR.G1► s
15o 6A. X 2.5 0 375 G.Pq VoI0$O
i BOTTOM ARE.Ai » j�'c SIF•. .
5.
-IOTA" DE51GN * o+Z5 G.PR '—
�j TOTAL_ pA 1 LY F%-OW = 330 v.P.D.
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PE2COI-ATION RATES iIN ZMIN oV-Lr=SS a II
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6T.
INJ. GAL. 51,8 `
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Z (000 INY, 574 TANK
GAL.. 507,o I
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C6RTIFIC m PI-o-r PI-.AW
PROFILE
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No SCALfa- SCALE
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� CERTIFY THAT 'FNE t-o�1.1�AT1oN SKo�N pL-AtJ REF EVEN GE �,
REP-SO W COMFU�6 WlTN-t HE- S 1 oEuLN E L oT- 7 3 ►I
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