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LOCUTION : SEWQC;E PERMIT MO.
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Iti1ST0,LLER 5 U&tAF- ADDRESS
BUILDER 5 Q &IAF- ADDRESS
Df�,TE PERMIT ISSUED � _�
ATE COMPLI &M-CE ISSUED : .
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THE COMMONWEALTH OF MASSACHUSETTS
BOARDF HEA T 1
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ApplirFatiaan -for Disposal Marks Tonstrnrtiaan Pprnift
Application is here y made for a Permit to Construct (611"or Repair ( ) an Individuua_ll Sewage
ewage Dispo7 al_
System at: �/o� ���U' W cc,,�� � o � �9�,_ '�U�7 l•7lrt �le���'���-
-------- --•----- _ola l� �c� 25``
---
L atio •Ad ess or Lot
�---- -- --� - --- ------------------------- -----------------•--•------•-•--__.._..._...-•----._._.....-.-.-..._.---•-••----------•....-------
O ner Address
�:--------- -•..�•----• ••-•--•--•- ------- �.... •---•---•-•••••--------•-•--•--•--•--•----------------•-•••-•--••------••--••••••••----••••--•---
nstal ler Address
U fipe of Building Size Lot--------....................Sq. feet
Dwelling JNO. of Bedrooms.............. ............................Expansion Attic ( ) Garbage Grinder ( )
aOther Other—Type of Building ---------------------------- No. of persons...---_.--.-------........•. Showers ( ) — Cafeteria fixtures ......................................................-----------•....---._...---------------..--..-...........----------------•---•-•-..---.....----
W Design Flow.................. ...-__ .----gallons per person per day. Total daily flow--, _8. --—
WSeptic T tiik-Liquid capacity/gallons Length---------------- Width.......-........ Diameter................ Depth---....----.....
x Disposal Trench—No/- -------------------- Width_._-_ .. - ota Len 1 _ -- - Total Qaching area--------------------sq. ft.
3 Seepage Pit No--...-._{---_----_- Diameter-l�_�.a.-�� et ------......... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( ) 6� /�� qkL — \`
a Percolation Test Results Performed b Date........... ------------- -�-----....
Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water....IW....--......
fs, Test Pit No. 2................minutes pe inch Depth of Test Pit-------------------- Depth to ground water...------------.........
/ `--- --- - -- -- - ------------- ---•----- ..................\--------
Description of Soil- •••% 1 -�
W ; «----- �...,. - Cysa� ---------------•------------
..................................................................... ...............U...... �•--- -77 .. ...... .. , ice!✓ -- -----
U Nature of Repairs or Alterations—Answer when applicable.--....----------------------------------------------------------------------------
-.... ----..
----------------------------------------- -•------•---.-------•----------------------•--------•------
--------------------------------------------------------------------------------------------------
Agreement:
,
The undersigned agrees to install the aforedescribed I-dividual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code e undersigned further ag of t place the ys in
operation until a Certificate of Compliance has been i y the board of health.
Signed.... - ._... ------ •----------------•• ••---- ......
Date
Application Approved B / ,r,/
PP PP Y --••- --• -• - ..•--•-•-- / D7�
Application Disapproved for the following reasons:----•------•---•-------•------•-•-••-•--•------------------------ ..............................................
-------------•---•--.._..-•-•----•--------._...---•--•--------•-•••-------••-•-•--•••--..._._...-•------•..-••......-.---••-------•-•-•-.--...._..--------..__.----------_-_.------....-..----.......__..
,�
Date
jPermitNo......................................................... Issued---s....-••-••••--------••--•-••••-•-...-.............
Date
Fsg..Aef................_
THE COMMONWEALTH OF. MASSACHUSETTS
BOARD F 'HEA T
r
. . ..�ju1Y1,...........OF.......
. •
Appliration -fur DiuVoiia1 Worko Tunuitrurtiun Prrntit
Application is,hereby made for awPermit to Construct (4<or Repair ( ) an Individual Sewage Dis o 11
System at:,,7*
- -------:---- ------ --4 `--•••-••-•---• ...�
t i 'Lo atio -Adrj�fess` or Lot
j_...._. ____ _ __ __________________________ ____________________________________________________________________________ __ ..._..__ ,y
? O ner Address
W
,a •------------- -
p f Installer Address
U pe of Build , Size Lot.............................
d P ��rSq: feet
Dwelling l��To. of Bedrooms_____________;..............
Attie ( ) Garbage Grinder ( )
Other—T '
a YPe of Buildin g -•-------------------------- No. of persons---------------- Showers ( ) — Cafeteria ( )
QOther fixtu es -------------------•-----------•----••--•----_------------ '--•--------•-_-.---:.........._......._..__._.........._.._._..............-----•.....
Design Flow.........._._..�Q. gallons per,,person per day- Total daily flow__„��_.—_" _____--.-..-_-gallons.
W
WSeptic Tank�L•igt id capacity gallons Le'ngth................. Width................ Diameter................ De')th................
x Disposal'Trench'. N _____________________ Width.___... .44ep
of Len Total leaching area..._.._._........._.sq. ft.
r =. s
Seepage Pit No._------ Diameter/�______ �ert_� . ........ Total leaching area------------------sq. it.
z Other Distribution box ( ) Dosing tank ( ) 1
a Percolatiop Test Results Performed by.............,.:_.."=---•--------------.....--------- D'ate_____._........._..._..._..j_.._.....
... ..
Test Pit No. •1•______..........minutes=per inch Depth of Test-Pit---------------------- Depth to ground water.... ...............
G4 Test Pit No. 2................minutes pe inch epth of Test'Pit.._:._.._..__._._.._,Depth to ground water............ ...........
••• •••--------- _-- • --.......
Description of Soil_Q_- {
W ,r2 {�
-----------------------------------•-------------..... :::
U - Nature'--of Repairs or Alterations—Answer when applicable.........................:................................
Agreement: `
The undersigned agrees to install the. aforedescribed dividual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary,Code. hte undersigned further a not t place the y m in
operation until a Certificate of Compliance has been ' y the board of health.
Signed... ._-- •---------•• •-•........ '-•.... ._ ...
/ .. • Date ./..
Application Approved By...�..-- �- •••••. ••- ••• '' --•- f f .7,1------•-
Date
Application Disapproved for the following reasons:--------- ....................................................................A.................................
......--..--•----•..........................................•-------•----=--•-•-•--------•-.._..-•-----•-...--•=-`•
R----------------•--------------------••-.._._._._...-----------•--..__..'_____-_-----
rf•ti Date
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PermitNo........................................................ Issued........................................... .............
` Date {
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THE COMMONWEALTWOF MASSACHUSETTS
BOARD F HEALTH,, ,
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......... I.OF......... .. .... ........... ,
W
(Irrtif irate of .Tampliaurr f ,,
T IS TO CE'Rl•IF fiat ndividual S wage Disposal System constructed ( r or Repaired ( }
by-
.... --'••-•••• ---= -- /--------------=----- -
" Y^► i� ---•-''T/'staller ...................................................
at.... --� i
has been installed-in accordance wifh'the provisions of A%cle� XI of.The State Sanitary Code s de ribed in the
LL
application for Disposal Works Construction Permit No...........&0-_ ..... ..... dated....__ ';_ ___ .._ ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E CONSTI 091) AS A GUARANT TFIAT THE
SYSTEM WILL FUNCTION SATISFACTORY. I��
DATE = Inspector--_ . ------- ....................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF7 HEALT `
! No._..�4 ..tom-= ..........OF............^......-- ...:.................... ................... FEE ..................
r Permission i reby granted % .-.._.. � _.. i...... .._...
. .'to Consttf`uct, ^ 4T Repa• (. )V Ind' u age Disposal stem
uA
Street
as shown on the application for Disposal Works Construction mit No . : _ .. . Dated___. sr,1 y'y_._____.__
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Board of Health
DATE v V
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FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i
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