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L O CATION SEWAGE PERMIT NO.
VILLAGE
INSSTTA LLER'S NAME i ADDRESS
S,UILDER OR yOWNER.
DATE PERMIT ISSUED
D A T E COMPLIANCE ISSUED=.:
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0-4604
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...7..771�...... ......
Appliration for Moposal 19orkii Tonstrurtion Prrmit
Application is'hereby,made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
0(
...M...... ...... ----------------�jt.. ...................................
Location-AdIress 4C . or Lot No.
It -- . .................... -I C ................................ ..................5_1�•... ............................................
Owner Address
............... ..... ........... ....... .......... . ........7 ...V.;��
k.... A I ............. .......0...
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.......7...............................Expansion Attic Garbage Grinder
PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
PL4 Other fixtures --------------------------------............. ............................
--------------*....... --------- ...... ........Design Flow.............�6.6 ..................gallons per person per day. Total daily flow........Z-3,0....*.............g�allons.
Septic Tank—' Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width..._......._...... Total Length........... Total leaching area....................sq. ft.
Seepage Pit No........I............ Diameterl2?.. Depth below inlet.................... Total leaching area..................sq. f t.
Z Other Distribution box Dosing tank
Percolation Test Results m .Test PitNo. 1 nutes 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...........................................................................................................................................................................
---------------------------------"--------------------------------------------*--------------------"------------------**---------*------*-------------------------- -----------
......................... ..........................................................................................................................................
;J:.............
Nature of Repairs or Alterations_—Answer when applicable........ .......LQ_00.....F..i...... .2........
U I.......
.......................... ...... .......: ...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'I'LE I A. , 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance b the boar
fsi-aned....
---------- ...... ........ .............. ..................
Date b
igned......
ApplicationApproved By.............. ...... 0.......................................................... ---I........ . .. Y .....
Date
Application Disapproved for the following reasons:.:..................................................... ..........I...........................................
........................................................................................................................................................................................................
Date
PermitNo..............Z........................................ Issued.......................................................
Daft
No.. �'f!Z F f FEs....%,.. .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'.C�.'.JX'`. .......OF....'... ,c•.v a :d f, I.. ............................
. ppliration for Dispaaallftrks Tonotrurtion itrrmi#
Application is hereby(made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: !
........�. ..».._;f;l ! �•�a..!_.. ...... ...1.!.`.:. .......
F. .:: ...........................
.. •-
Location-Address or Lot No.
....... - . . :. : ._ �- �'•-��. ...................•--................---
.._ .. .. ..-- --- -
- Owner
A�!dtidr/es s
0,0 � ........... ...----................ ..._...-----•--- ...o--- _...
/( C
Installer Address
Type of Building Size Lot.....................:......Sq. feet
U Dwelling—No. of Bedrooms..._._7...............................Expansion Attic ( ) /Garbage Grinder ( )
a'4 Other—Type of Building _. No. of persons............................ Showers
YP g -------------------•------ p ( ) — Cafeteria ( )
Otherfixtures ------------------------ ......._---------------------
WW Design Flow............ ..................gallons per person per day. Total daily flow..... . .._._....:......._....gallons.
WSeptic Tank—Liquid*ca.pacity............gallons Length________________ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No------- ............. Diameter!? �i........ Depth below inlet.................... Total leaching area..................sq. ft.
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........................
fi Test Pit.No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •------•-----------------------------------------•-•-------•-----•----•-------•-•-----------.............--•-------..:-•-----._.......--------•--......------
Descriptionof Soil........................................................................................................................................................................
-----_--•--
U ..............•--------•---•-•-----------•-•-•-•---••---•••------......- .._......_.....---•-•-----------------...-•--------..._........--------------...._......_...----•-
-----
xW ..........................-..........................................................................--•---------------------=---•-....------------.......-••--•-••-
-------- ..
U Nature of Repairs or Alterations—Answerrwhen applicable...__, r ).Y?._._..l.o_-.�a.�?.....0..;:4- ___1 -' _. �.....__.
�-./ t� _ .!? P-: S T t r- C Ga , _<----- �r� 't '' - ` ?_!.1..............
: -f . - - - -
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ. 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. s
'Signed ... :----. ��G ....`? "' .. �.... ....s
Date
Application Approved By.....
1...... .0.........../ `..
Date
Application Disapproved for the following reasons:-------••-•........................-----------------•----•--•-•-----------•--:.........---•--------...........
--•-----------------•------------•--•-------•-------•-------•---•--------..__....._-:..__..._....._...._..-•----•-----•------•-----••---......----:...-•----------------....---.__..•-•------------•----
Date
Permit No----------------------------------------------------- -- Issued..........................................
.....--------
Date
THE COMMONWEALTH OF MASSACHUSETTS
{ BOARD OF HEALTH
.........................................OF................................................................................
Tafifirtt#r of Toutphana
THIS IS TO CERTIFY; That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
xl (co beefs ..... -
by .._........ -�---•....................�� -G---._....--rram+f....----G----------•-----•-•-•--•---•------•-----------
1 Installer
atZ �Y._1:. ..... ........�---•--._------------• l- ._............_.__.._.............. ----- ......_..._.....-----._......
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ___ dated--------- �..... ............
THE ISSUANCE OF THIS CERTIFICATE SHALL.NOT BE CON7;_
A GUARANTEE THAT THE
SYSTEM WILL FU CTI N SATISFACTORY.
DATE--------------•-_�,1 ,�_7 l !... Inspector ---...
THE COMMONWEALTH OF MASSAC HLITTS,
BOARD OF HEALTH
........................................ O F......:.......................................:................................... ?
No�.. ............ .. FEE..... ........
Disposal orko :Ton#rrttr#ion "prrmi#
Permission is hereby granted ----------=-�--- ...............................:
to Construct ( or Repair ( ,) an Indivi�uall Sewage Disposal System
at No.••. 1.?=-.....f!.11,,,,., C ;t
------------------•-•------•--•----...--_--_••----••--------•--..............------•--------•--•-•••-------------•--•-•----•---•--•----• ..................................
Street
as shown on the application for Disposal Works Construction Permit No.�._ _.��-'_ Dated.__4�2 1//`.tb_:.
r- J
Board of Health
DATE C --------_------------------•---------•--