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No. 12534
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OR FORESTRY MIN.RECYCLED
INITIATIVE CONTENT1096�
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LOCATION f SEWAGE PERMIT NO.
VILLAGE '
INSTALLER'S NAME & ADDRESS
67 v -
B U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
Zq
No.... ......�29/ ..., Fes$....... . .�'.........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
................................................._0 F.......................................------------....----...........................----
ApplirFation for Disposal Works Tonstrnrtion ami#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...��'.?.....�' . .x.�....., � L ...� �� .:...... - •-•-------------•-•---••-----.....---••--------••-------------.......----....---------
LKcati n-Address or Lot No.
> = --••-•-••-••-------------- ---------------------------------------------.----------.......--..------------.......•••.......•.
W Owner Address
..1..:..�glYl__4' L7_"`...........................•-----••...............--.--•- ............... ddr . -q.._..._.
Installer Address
U Type of Building Size Lot../-�... ..S . feet
�-, Dwelling—No. of Bedrooms._.__. .............................Expansion Attic ( ) Garbage Grinder ( )
a
aOther—Type of Building ._fE.`- No. of persons--------- .......... Showers Cafeteria ( )
d 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........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 9 •••-•--•----•-••••----------•-......-•._...--•••-••..••--......••••••......-•••-•---•••....................................................................
Description of Soil....................................................................................------------------------....------------------------------------------....------••-
x
U --•-•••---•--•----•••----•••-•••-•-•---•................•-•-•-......•-•----•...•---•-•---•-•----••••----•--••••••---••••--------•••-••••------••-•-•--•••••-•---••--•-••-•-•-----•------•-••--.....--••-
w
x -•----•---••----...••• ----••---••••••••••••-••-•-••----•-•-•••••-••-•-•-••••-••-•-•. --•• -••-------------------•---•-g---- ------------- p........
U Nature of Repairs or Alterations—Answer when applicable...U. _..(k.a_% _ [�1 _X.�---_-.�E?_S? L-_...____.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI',LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been . s th boa of ealth.
Signed. =-•- • •-•....... ----•... ...... • •-•--•.---- '.� ...
Dat
Application Approved BY ---� ---- ... .. .._......-•-._.......-••------••.---•• ........
Date
Application Disapproved for the following reason .--------•---•••---....-•-•-•--•••-••-•--•---•---••••••••---•-••••-----•-•----•-•-•---••----••--••••-•-•-•-•-•-•-
....................................•---•-----•---------••--------•----------------•------------------••-------------------------------------------------------------------------------....-----
Date
PermitNo......................................................... Issued.....................................................
Date
-------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.......... ..........................................................................
(Srrfifiratr of Toutpliunrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----------. j� .--------•.._..---.. .. ..- . ---------•---- ------------------------------------------------
�I Installer
at............Cd ..•--...... -- .--•.--•- ---�'' ...................................................
has been insf lied in accord th the pro TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......9-11/ ...`1t1....... dated—..............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WIL)L FU�ytG��TION SATISFACTORY.
DATE i1.1...................................................... Inspector .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No. ...........................................OF..------••---._......................................................................Z. MEL
FEE..
Ubpooul Workv Tonotrttr#ion rruti#
Permission is hereby granted--- `"--`-------------•----'-------------•-•--•-----•-•.......---•••...............................................
to Construct or;Re air an Individual ewa e Di osal S�yst � "�"
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated-: ............................... ..
`..
............. �- .. . - ---.. --..._._.............................. ..........
DATE. Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON �-
'rr> .
i
No FFZ
. ............... ...... ... ..............
THE COMMONWEALTH OF MASSACHUSETTS N_
BOARD OF HEALTH
...........................................OF................................_......
Appliration for Disposal Works Toustrurtion "trutit
V
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
!�Jz.-r---R A....................... R.2............I...........................................................................
cal n-Address or Lot No.
... ........r...........................
.. ...... .. .. ------------------------ ......................................................................
0 ne Address
............................... ..................................................................................................
------------
-iier Address
...ja----------!.Yns
Type of Building Size ...Sq. feet
Dwelling—No. of Bedrooms.....7. ...............................Expansion Attic Garbage Grinder
P4 Other—Type of Building _/'V ...-I.Com No. of persons......... .............. Showers Cafeteria
P-4 Other fixtures ..................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
.A.....A
WSeptic Tank—Liquid'capacity............gallons Length................ Width.............._. Diameter__-____....._... Depth................
Disposal Trench—No..................... Width............._._.... Total Length............._...... Total leaching area....................sq. ft.
> Seepage Pit No..................... Diameter.............__..... Depth below inlet.-.,.,................ Total leaching area..................sq. f t.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I...........:....minutes per inch Depth of Test Pit...._..........._._. Depth to ground water........................
04 Test Pit No. 2................minutes per inch Depth of Test Pit.._............._... Depth to ground water...................._...
P4 ----------------------------------*-------*-----------------------------------....*--------------------*------------------------------------------------------
0 Description of Soil................7............................................................................................................I..............I.............................
....................... .................................................................................................................................................................................
.......................................................................................................................... ----;. Qr---------------k----------P............... ----------
- ----------------
U Nature of Repairs or Alterations—Answer when applicable-1.).,b... . ....... ..........
............ .......................................................................................
Agreement: Y
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 1I'=4 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beeneKs ed t e bo Ci talth.
Signed . ........ ....... ........... . ...... V_
a.1
. _,0
Application Approved By....... . ........................................ ------- Y-------
Date
Application Disapproved for the following reason ........................**'*'*----------------*--------------------------------------------------------------
.....................................................................................................................
Date
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