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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
!,-��E�/,�►�LT H
�. CW ..............OF..... .!'�izr'! '1.1./s� -----------..............'------
��Xpvftratiou for %gpoiial Workii Tonstrurtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
�A �" v'�u 2
Ir ............... •-_. .hf....._.... ... ......
Loc i -Address or t No.
.�_L
--- ---....--••------•-..:- fi e .................._
wnere -T_ (/f sa � dd�� .. / y0
Installer Address 95,=5, 04
d Type of Building Size Lot...............�....--......S�-fee
Dwelling—No. of Bedrooms............... .........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q+ Other fixtures -----------•-•--------------•- -
g
W Design Flow............... yy..........gallons per person per dray. Total d�ily flow__._..._.___.___.3-��-�d_.••...:._.'..gallons..
WSeptic Tank—Liquid*capacity!_ M_gallons Length...f-'�_.. Width._d-.._ t�'--j Diameter________________ Depth.___^ ...
x Disposal Trench—No_____________________ Widthl.................... Total Length..................... Total leaching area............. .....sq. ft.
�.Seepage Pit No----------- _-_.__.. iameter._j!:--- Depth below inlet_•.�............ Total leaching area..� ....sq. ft.
z Other Distribution box ( Dosing tank ( ) I
'-' Percolation Test Results Performed by . ram-.••�.I.........�-"V - -Date.......�_ _�A:4 n1........._..
--
aa Test Pit No. I......7Z.....minutes per inch Depth of Test Pit.......1 L9_...... Depth to ground water.....+ `............
Test Pit No. 2................minutes per inch Depth of Test Pit-_.______________-•• Depth to ground water........................
P4 --------•--------------------------•------------•--•------------------•--•--._...............................................................................
A Au
D Description of Soil. w i t,'4 V�..---•--....!.r W I>........
V -------------------------------•---•--•----•-------------------•--------------......-----••••---••.
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 TITLE 5 of the State Sanitary Coc
—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i by the b r _of ealt .
3 h
Signe ......... ............................... 'Dat
Application Approved By--•---.. •.....--• •- -•---•......--••-•-- --•3 -•--•- ........
Date
Application Disapproved for the following reasons:-----•-•------------------`----------•---------------------------------------------;•--•••....--••-•--••••.......
-•--•-••---..--••-•-•-----••----•-...••---•-----•••••..............•-•--•-•---......----....---•-----•--•--------------•--------------------------------------------------------. ......................
Date
PermitNo.. --------------------- Issued--------------------------•---•-----•------------
^' Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........�_OWO..................OF....R—.s*... jww a.............................................
Tn tifirFatr of TompliFaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by �.. � - Installer
------------------•---------`-----------------------------•-•----:------------------------------------..--------------------
I �_
at -` -------> ----------------•-----------------•------------------------- .._...-------------------
/ .
has been installed in accordance with the provisions of TW'55,of The State Sanitary Code as desc ibed in the
application for Disposal Works Construction Permit No. ... _.�______.... dated
THE THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
2� ..........T(XV.0............OF......... . -{� `!'7.. A!C� L-@ ................................... �yy did
No.... .. ! FEE..,eS.E,......-
�i���a aal irk �.ataa��ri�aa� f Fermi#
Permission 1 hereby granted..... -••••-.V....-••.._..-••-•-1� °-•---------•---
to Construct (I or Impair ( ) an ndividual Sewage Disposal System
atNo.•-•---.....� ----•-•--- '. ........�- ,1`1' --------------------------------------------------------------
j Street _ q,
as shown on the application for Disposal Works Construction Per o.___��//J_ ��jjated___ _ - -- ------1-jl------•-
scare of Health. .
DATE.................................. _
FORM 12$5 .HOBBS & WARREN` INC.. PUBLISHERS - `
t.'
• (- --- Fxs....�-�.........�f....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH {
t/i l OF._ l 'h- .: ----------------•----.------------
Applira#ion for Bisposal Vlirkg Tonstrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
0.3
Loc i n Address or t No.
....... _.._ _.. . : . :.. -- ------•-- --x- ��R��� ................
Owner(,�('� ® �,@Ad r � j l
a --•••-------------------- ------....... .. _:r.a.i:!4.m�........................... ---.............•.. .�C+a:.<'`'°�...=-9.. �,.1..�-`.I ._._...-•--- •----•-
Installer Address ,.. ,- 4
Type of Building Size Lot............................ -q—fett
U Dwelling—No. of Bedrooms.............. ...............::.........Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
P4Other fixtures -----•------------------- -•-----------•------.-----------•---•-------••••-•-•-----------------------... �. --------..._...........------
W Design Flow....................��? _________._____._gallons per person per day. Total daily flow................ ...........gallons
WSeptic Tank—Liquid capacity '..gallons Length.. _. .___ Width. ._..9.i _. Diameter................ Depth_' _..�......
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.................._sq. ft.
Seepage Pit No.......... ......... Diameter........... ._... Depth below inlet_.. ............ Total leaching area..Z44.....sq. ft.
Z Other Distribution box ( Dosing tank ( )
aPercolation Test Results Performed by .............................................. .Date.......dtJ `�_____________
Test Pit No. 1..... r___.minutes per inch Depth of Test Pit......1V....... Depth to ground water.... ...............
Test Pit No. 2................minutes per inch Depth of Test Pit-___.___•--.____._._ Depth to ground water........................
----------------------------------------------• .............................................................................................................
0 Description of Soil.................e-_'•:• %0-------I,Gl'b10sw1. %
•••-- ------•--------•••----•-------------••-••••-----•••--••-•••......-••••-••••-•-----•---
V -----------------------------
•-------------------------------------------------
---•-------------•-
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 TITI:; 5 of the State Sanitary Ais's
The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beby the b d Of h*Ih*�Signe ..............
J;ae
Application Approved By......... or .................. Dat . ►,,..._..
Application Disapproved for the following reasons:.....................
Date
Permit N,o--------------------------:: Issued `-------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........low-o............... .OF.... Aetll1'",648............................................
01rdifirFatr of Tomplitaatrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( P<or Repaired ( )
by--------------NeC,4•-,:_�O ............................................ -------------------------------------------------------------•---------••--•-----•-;--•------......---
Installer
has been installed in accordaanncee with the provisions of T i r 5 of The State Sanitary Code as described in,the
application for Disposal Works Construction Permit No:____ _-.____ '_:�_'_......... dated_17_ �..b=_�. . ..................
d.
THE ISSUANCE OF THIS CERTIFICATE SHALL NO. ,EE CONSTRUED AS A GUARANTEE THAT THE,
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................................................................:.... Inspector_.::.....===.......................................................................
THE COMMONWEALTH OF MASSACHUSETTS'
BOARD OF HEALTH
'T .......... . ' ...........O F....... y(.1 ........................ K'
No...... .:.. s�: Faa..,, ..
=al orkg,�'+Permission is hereby granted.... A.......4, WT...............................................................
to Construct ( or Repair ( ) an Individual Sewage Disposal System
at No........... ------6AJ-----
Street '
as shown on the application for Disposal Works Construction Per 0. .:.. ..... ated.__ "'_ _'! ....___._-.._
B oard o e?trh_. y'
--••---•-•------
DATE................................. _-
,. FORM 125�: ,HOBBS & WARRERq, INC., PUBLISHERS - ,
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