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LOCATION SE GE PERMIT
VILLAGE �j
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INS TA L L E 'S NAME i ADDRESS
8U11DER OR OWNER
DATE PERMIT ISSUED
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DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHusETTS
BOAR® OF HEALTH
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Appliration for Dhipasa1 Warks Tonstrn.rtion remit
Application is hereby made for a Permit to Construct ( ) or Repair ( t<an Individual Sewage Disposal
System at
----1•� a.�c: ��r.... x .............. ........-L eNss
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-----•--------------------.---------------
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..bQ.e� .. ••••••--- •----•..............•--..............
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'Installer t Address
Type of Building // Size Lot............................Sq. feet .
U Dwelling�No. of Bedrooms..........................�/-__----_.•-•-Expansion Attic ( ) Garbage Grinder (�
pa, Other—Type of Building No. of persons.-.-_-----•:.-•.---..--...•. Showers — Cafeteria
a' Other fixtu
---•------••--•---------------------------------------------------------------•-----------------------•---------_-_--_----
W Design Flow..............►1---.........-...............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 ( ) k
Percolation Test Results Performed by.......................................................................... Date........................................
a
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fr Test Pit No. 2................minutes per,inch Depth of Test Pit.................... Depth to ground water.........................
O Description of Soil '. :. -•�T
..................................................................................................
x
V
----------------
W
U Nature of Repairs or Alterations—Answer when applicable.-- .- ��. . : - ��___________________________________
" .
•••.-...---••--- t� �..�-•------- �. -------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI:'LZ 5 of the State Sanitary C de— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en sued by the board ojhe Ah.
Sign i=--_"= l------------- -�C.I"I�D-.IL-----
� Date
Application Approved By------h`"�--- ---- ------ - - ---� — �l 17"7
Date
Application Disapproved for the following reasons:--------•---•------ ----•....................................................................................
...................•......-•--••---•-•--.......•..-----------......-•-----•------....---------•--•-----...---•-•----------------------------------•----------------"---------------------------••-•-----
y Date
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Permit No......................................................... Issued--•-i----......---••----f
^
.................. -----•
Date
No............. ��_ Fss..:k.........€...j.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. +.. %).....OF........., `4.. '' -.._._..............•--
Applirtt#iun for Disposal Works Tonstrurtion thrutit
Application is hereby made for a Permit to Construct ( ) or Repair (IoT an Individual Sewage Disposal
System at,:
-•-••)— s.L ': . - '-,'�tv' .' .................... ............••----------------•---••----.... ..........-----------•----....-----------
cation- dress or LA No.
• - -'... ............................................. ••••--• t `" � ---................--•................................
O"ner Add eas
Installer Address
Type of Building Size Lot..:.........................Sq. feet
V Dwelling No. of Bedrooms_________________________; ...............Expansion Attic ( ) Garbage Grinder ( /jp
'04 4 Other—' Type of Building No. of persons____________________________ Showers — Cafeteria
a Other fixtur,, s ...
d J ---•------------------------•..-------•---•--------------
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. I................minutes per inch Depth of Test Pit..........._........ Depth to ground water........................ J
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ,
................•--......-•-------..._..------•--• t"
O Description of Soil-----.....� ? ( S t _ ." .._'� _ ,t 1 � '°. _.__.._...
x
V •--•---------------•--._.......--------------•-----------•--•--•--•-------•----•--...:.------••--•--•----•---••-•••--•-•-
•--•------•-••---•------•-----------------•-----•------------.._...-------•--•-•-------._.-•----------...-•-•-
U Nature of Repairs or Alterations—Answer when applicable. " • �_ " , i:- Dt`-: _---
_______________________
Agreement:
w 1
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of A ITL:
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b.en sued by the board oj lieghh.
f r��
-----
Sign ::_ ................................ ...
Application Approved By___- __ r_tom:.--- - l. tt
__ ,
Application Disapproved for the following reasons_.....................61............................................._.........................
Date-----•----•-N
'ftk_ Date
PermitNo......................................................... Issued.......................................................
Date
I
THE COMMONW )kLTH OF MASSACHUSETTS
BOAR6 OF HEALTH
"� �rr#ifirtt�e of �nnt�rlitt�tr�e � � ..
THIS�IS TO CERTIFY, TIjIat the Individual Sewage Disposal".System constructed ( ) or Repaired ( )
by............ .... .. C{ C r_ F - ? A _-}"'f ..:r--...:....._..------...-•---------------------- ----•-----------------•-
er
f at. 'i� "� `i '"'q�" ..... Install
C
r,
has been installed in accordance with the provisions of T " ' ' ` of The State Sanitary Code as described in the
f �•-----•-••------ dated---- 7._7f- --------
application for Disposal Works Construction Permit No __________
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
G�
DATE ..._.,/v.......Z .................................... Inspector------- --------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
j
�, k,� ........OF............. 1.4 '^ ....................
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N l : FEE... .z. . ......
Disposal Works Tunutrnr#iun Wrmit
Permission is herebyY._anted__._.�7__.__ __ '.._.. _ .. .. __ (-.
l
to Construct ( ) or Repair ( L-�r an Individ al Sewage Disposal System i
- ------- . . � ... ................
w Street f
as shown on the application for Disposal Works Construction Permit` o.____. " (______. ) ted__ /` _ `_ ........... a _
✓- �' t' l�Vic_ ...........-•-------. �-
Board of Health -
......................................... ,
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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