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LOCATION : 5EWo,C,E PERMIT UO.
SEWIMSTQL�LEAR 5 1J' &ME ADDR
BUILDER 5 Q L VAF- ADDRESS
DN.-TE PERWT ISSUED =-rMS 7- _.
DATE CONAPLI WACE ISSUED :
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No.....q.1-......... Flm..... .................
THE COMMONWEALTH OF MASSACHUSETTS "
BOARD QF HEALTH
..............OF...... '.... .
Appliratinn -for Bi,tipufitt1 Works ( onfi#rur on jhrmil
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
1`�� T�/ 44�02---------------------------------- ---••---- - --- -- -•---•---------------•-•---------•--•-----------
Location_Address or Lot No.
.............. ....................................... ----- --=•-••-••-•-•••-•-•••-•-•...•••..._..-••-•----•-••--.._.......••_...
Owner Address
Installer Address
UType of Building Size Lot............................Sq. feet
,-� Dwelling—No. of Bedrooms............-�K___________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' 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. It.
z Other Distribution box ( ) Dosing tank ( )
►" Percolation Test Results Performed by....................•--.....------------------------------...._......._.. Date------------------------------------....
Test Pit No. I................riiinutes per inch Depth of "Pest Pit.................... Depth to ground water:.-.-.-----_------.-. -
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------------------_
- .•••••••._.._ -----------••---.........................................................
9
Ox -
_ -----------------------------------------------------•---•---------------
Description of Soil ...................................................
-------------------- -------------------------•-- ----------------------------------------------------•--------------•-----------------------------------•------..•..............-------•---------------
V Nature of Repairs or Alterations—Answer when applicable.........................:....... .Ci .............................................................
.......................................... -------1(a------- 81CfdF/?........%C L.P'�/r#_.... --------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I 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 boardof health. r
Sign �`G=` `--• -•-•-•________________________•------•--_ " �--- . ---
.v' Date
Application Approved By--fit Z��' - ._ ... :.t�....-
Date
Application Disapproved for the following reasons:.............................
•----•-•--------------------------------------------------------------------•-•-
------•----------•-------------------------------••••••••••••••••-•----•--•------•-•••••--•••••••••-••---.•••••••-•••••--••-•----••••--•--•••••••••••_...••••----•-----------•----------..---...•••••••--
nDate
Permit No.---•----•••••--••••••••-••••--•••--_••• ...... Issued._.Amr-e�-•-- �•---....
,
�ra�.ri• ------ --
No.____Q__l:_.......... FEs....Z,..............
THE COMMONWEALTH OF MASSACHUSETTS
F i-6LTH - .�'t�BOARD
...............OF..... . ....
Appliratiun -fur Diupuuttl Workii Tonstr) an
un Vrrmit
Application is hereby°made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
System at:
colt
............. �"laf�' d1*'•Bcl------•--------------------------- ------•---- _-- ----------- 'l - -..
-------------•-•---------------•-----
I Location-Address or Lot No.
Owner _ ``-ArdaTess
- . r - - ,Installer Address
UType of Building Size Lot_?_________________________Sq. feet !
Dwelling—No. of Bedrooms............-3___________________________Expansion Attic ( ) .,-_,-`'Garbage Grinder ( )
per, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a
Other fixtures .�
d ---------------------------------------------------------------•------------------- ----------------------------------...-----
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 ( )
aPercolation Test Results Performed by--------------•--------••----•--•---------....•----•---------�........... Date........................................
a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
�14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
9 -----...... ............. `. =------------••..........................................................
O Description of Soil............. r�,,.' ',01.
- l . ----------------------------------------------------------••••----------------
U -------------------------------------------------------------------------••-•----------•••-•-••-...---•-••------•------••----•------------•--------••---------•-••-•----------------••••-•------------
w
V Nature of Repairs or Alterations—Answer when applicable...:.....................__._..__.._......._.....-._.._.__....._____.____.__....__.____........
............
--.............................f5W- 14��-----�XB �°,+� flsrtrr�------- ........ :r-:....-------•--•-------------------------.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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 boar'&of health.
Sig `r`"
• ��� ,� Date - ��
-Application Approved By------ = >t3�' � 'S
Date
Application Disapproved for the following reasons_____________________________ ___
------------------------------------••• ----------•---•---••-••-•----•-••-------•-•••-•-•-•----•--••-••••-----••----=- ----------------------------------------------------------------------•-
- Date`
PermitNo......................................................... Issued..............
Date
LS !`^;
THE COMMONWEALTH OF MASSACHUSETTS
'BOARD _QF HEALT
r- 0.G, �l. .............0F.,..t . ........". ....... ...... ..........
(1:11 rtifirdtr of TIMPHaurr
HIS IS TO CER" IF , T e Individual Sewage Disposal System constructed ) or Repaired ( )
In lle
at.----- ` -• - ---- -- L-- ------ ....... X/ - ----•--------- ......
has en installed in accordance..with the-provisions-•of• lc - I o The State Sanitary'de a described in the
1 application.for Disposal Works Construction Permit N 7�`J' �...............
7
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 HEALTH
..........of......... ,.yE.t .mod
...rGrl.. . :..............................................
No. ••-•-••r-�•---- FEE
�i� u 1 urk n tr, nrrtttit
Permission is hereby granted_- -- ------ = . --- •--• /' ---- --- ..........................................
to Constrict �/ ) or air ( -, an Individual Se age D' osal stem
at NO..`.: -dl�tt-- .�..
`` .
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as shown o he application for Disposal Works Constructi rmit o ... __.._. Dated._..3._ __ .._.�_ S.____.__
h7�L��L
` ` � Board of Health •
DATE- - - �- t/-- ----..................,. .. .w. I
FORM 1255 BS &-WARREN.. INC".'PUBLISHER'S': -^
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