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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-------..__t l�.................OF.... AeF—'--tr`r 1. Z
Appltra#Hatt for Uhipoiia1 Vorkti Tomi#rur#tint Prrutit
Application is hereby made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal
System�a
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) �
.........
---_... --------------- L ........--•-•-
........- atio a- .; ... _........................�L_
- caner -•---A--r ss
w �� � ....
,� ----------------- - : 7Tf�
Installer Address
Type of Building Size Lot......
Dwelling—No. of Bedrooms..................3......
..._............Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building _______________ No. of persons__..___._.__________._______ Showers — Cafeteria
44 Other fixtur s .................•-•----•----------••--•-------•----...-------------•-•----•-•-------•---- ...........................................................
WDesign Flow_______________��_ _....__ gallons per person pFr day. Total daily flow..................... � ..........ga�Ilons.E'
Gd Septic T�Liquid capacity _gallons Length___ _ _._ Width__-1 Diameter________________ Depth__��Disposal h—No_ ____________________ Width.....l0.......... Total Length.....Z�...... Total leaching,area.... `_!�P____sq. ft.
Seepage Pit No------------------- Diameter.................... Depth below inlet....___.. ...__ Total leaching area.__::............sq. ft.
Other Distribution box (� Dosin tank
z rr
V �_._..= `a9i. _ g'Date: --_ W-11
Percolation Test Results Performed b . --•-
al Test Pit No. 1.......7 .minutes per inch Depth of Test Pit........9_____.___ Depth to ground water_.___________________
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to around water..................
o .......................................................... ------------ - � .
Description of Soil------------------!L f.....•------M 1 a l!l. ��� � --...-----------------•---•---._.....--------
x
W -•---•------------------------------------------•--------=---------••-••------------------------------ --•-----•-----•--.....---------------•••-•--•••----•-•••-•------------- .........................
U 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 TITiZ 5 of the State Sanitary Code he undersi ned further agrees not to place t e sy em in
operation until a Certificate of Compliance has been issu the bo I of It 7
Date
Application Approved BY------- - - . XSie
G' M��
Date
Application Disapproved for the following reasons________________ --_________________________________________-_-_______________•----- ---....--•----
......---•----•--•------------------------•-•-•--•------•--------•---------•---••-•--.......-•---....-•-•..............................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .1 .0..................0 F........... `��71 rr' ..................................
Trr#gfirtar of Tlautplia trr
T W IS TO CE TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by_..._. ....�9l cak._._._... .1..........................................-----------..._.__....--•----•-----•-•--------•-----•-•--•--•--........-----......._..._..-------........_
_ Installer
at.---••--•• �•- --------- ••---•-•---.-----------------------•-------•-
has been installed in accordance with the provisions of T 5 of T e State Sanitary Code a described in the
application for Disposal Works Construction Permit Na_ ---1 �j. .____._____ da.ted.....�.�-�_'-�c�e_______________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT.THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................•---------------------------------------•-•-------------••-- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.• 4�1
/3® h�.Q�...........OF.............. {'`� ......_........._.........._. �~ o1
N ........... FEE....--•••---•..........
..
Permission is ereby grante .... '
to Construor Repair n Individual Sewage e/Lj
bsal S stem
atNo.......... -1------------- ------- --_ .._.--- - tStreet
as shown.on the application for Disposal �I rks Co ~ruction mit ___ Dated—. �_� �_�............
�.
F u�J�1
Board of H th .
a.
DATE..............................
'rt
FORM 1255 HOBBS & WARREN, INC., PV,:✓t: ISHERS
No........................ .............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH
OF.....nAgL:MM ....................................................... ...... .......................
Appliration for Bhqpoiial Workii Tomitrurtion Vamit-",
Application (Voe,
is hereby made for a Permit-.,to:Construct or Repair an Individual Sewage Disposal
System at:
t�Atj Uoe W Tue
........... ........r......... ......... 3
........................ ........................ ---------------------------------------or Iq�N .L
.....I....
.......... .............. ....................� .... ..................................
n Address
.................... ... . ... ....!.. . ......................
Installer Address
Type of Building Size Lot..._.�::..... ..-rSq-'1e'-et
U Dwelling—No. of Bedrooms............ ..................Expansion Attic Garbage Grinder...........:�.
i... f — Cafeteria 44 Other—Type of Building ................... No. o persons............................ Showers
04 Other fixtures .....................................................................................................................................................
<11 Design Flow............... a per day. Total daily flow-------------S.I.q............alons.
................I............__gallons per person 5'
P4 Septic T Liquid capacitylOCeOLgallons �ength--41�' ---- .........
Width 1.12"Diameter................ Deptli-5
x Disposal&h—No. .................... Width.._IQ........... Total Length____-Z5........ Total leaching area`01----0----sq. f t.
'Seepage Pit No_____________________ Diameter........... ...... Depth below jw inlet.__ o 'e-
...... Total leaching area..................sq. f t.
Z Other Distribution box (V) Dosing,tank ( ) 041- - - 0
Percolation Test Results Performed by.�-Z`kn ,�.U*a.........tc Date_._....7777::T�4-..X4-40h
1 ....
Test Pit No. 1......77 minutes per inch Depth of Test Pit-_____.1.... Depth to ground water_____ _______________
Test Pit No. 2................minutes per inch Depth of Test Pit..................... DePth to groundLvater------..............
..........................................................................
0 ..........
Descriptionof Soil...............y ..........M1�32!N�m....... ....................................��Ww............ !..............
------------------------------
---------------------------------------------------------*----------------*"*--------- ---------------------------
.................................................... .......................................................I...........................................w............................... ......
U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------........................................
............W............................................................................................. .................I......W......................W.......W.......W...................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
"the provisions of TITLE: The 5 of the State Sanitary Code-Ij undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been P isst1Pe&d ,,
Da t e
the bi5oftimtaltSi 7
............. ..............
Application Approved By.
Date -7
Application Disapproved for the following reasons:............... .............................................
............. .. ...........---------
.............................................. ........ ..................................................................W....... ......................................................
Date
PermitNo......................... ............................ IssuedL................w-w....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... .................. .OF... .......15"..
.....................
Trrftfiratr of Tompliatta
THJS ISO CE T Y That the Individual Sewage Disposal System constructed /) or Repaired BTIF ,
.......G�. T.!................................ Vk. ............... ....................................................................................................
Installer
at ...... .....4.......... ................................................................................... ..............
11
has been stalled in accor ance with the provisions of r 5 oLTbe State Sanitary Code as'described in the
application for Disposal Works Construction Permit No ....IJA------------ dated--- 3---- ---- ��„---•-.-•.-_--_.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Iftsp or........................................ .................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........OF........ 45111166.(Z..............................
N06) ........... ........ ... 11/' FEE...rv?..............
Perm'ission,j ereby granted'.: - ------ .............. ..............
.......... ........ - - ------ - -----------
...........
to ConStru or Repair an Individual SciArage Di -,c-' stern
............................................
at No....Wt (!�....... ------t�A............ . . . ............. .......... ...
- I Street
as shown on the application for Disposal
c i n", mit ... . .......... Dated____S------f.... .....7-----------
t
.......................................
DATE.........................................................
.............
FORM 1255 HOBBS & WARREN; INC...
ISHERS
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