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LOCATION SEWAGE, PERMIT NO.
VILLAGE
I N S T A LLER'S NAME i ADDRESS
R U I L D E R OR OWNER
DATE PERMIT ISSUED
D A T E COMPLIANCE ISSUED
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-3ARMI5090EALTH DEPT.
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OMMEMMA 026M Fss.............
No................_...._.. 1a rUwyS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T. .lx�. .............0F...
.....„
Appliratinn for Dispasal Works Tonstrurtiun Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
•--.........1.. .......1-!:1::!-o..W ...Q `+v: .._... 1 }( w ti'r s... .......................................
Location-Address
T7, Nc17 �:� YS��:+a``� /L� ^ .'rgj.............4U�G.:`... Iot IVo.
..... w ...............................................
Address
a �- �� r...... rP_! ................ 3.....rto� ..
Installer
Address q- '
Type of Building Size Lot............................S feet
�.. Dwelling—No. of Bedrooms...... .................................Expansion Attic ( ) Garbage Grinder ( )
a'4 Other—T e of Buildin
YP g -••••---•----•-•---------:-- No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixt res .
W Design Flow.......r� ......................gallons per personpyer day. Total daily flow.........i�.-._C�....................gallons.
WSeptic Tank-4-Liquid capacity.Z0.gaIIons Length..S.'6._.. Width... Diameter................ Depth................
x Disposal Trench-No..................... Width.................... Total Length......_.._._..._.... Total leaching area....................sq. ft.
Seepage Pit No....1............... Diameter...../..0......... Depth below inlet_s,S���.-.-_. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1.4 Percolation Test Results Performed by.......................................................................... Date.........................................
,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth.to ground water........................
f� Test Pit No. 2................minutes per 'inch Depth of Test Pit..................... Depth to ground water..........
...------ -_.
0 Ra -----------------•------------•---.:..--••------...-•------...-•---...................------....._--.........................................................
Description of Soil...........................••-•-----•-•-••--•-•------------.......---•-•-•---•----•------•----------...--•----•••----•--------.........:----.........----....._--•------
(� -----------------
...-.---------
-.---------------------------------------
--=-----------------
..........---------------
.•---..--------
--------------------
•----------------------
-------
-------
_.......
W
U Nature of Repairs or Alterations—Answer when applicable-----l�: .... ..%�"L- •-- ._.. 4
F7c._.7 1V .......... U7. ..... _. � ... /za.�.. ..................
Agreement: ri
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITi.i, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hak\en-i mtd_by the board - th.
Signed.....---=------------------- - ----•----._.. ..._... .--••------------...--- ---�------��-----•-
AApplication Approved B ��....::................. Date
PP PP Y ....._... ..
s Date
Application Disapproved for the following reasons:................................................................................................................
...............•---•-•-------........---•--------.....---------•--•-----•-•-----••----------•---....--------•---....-•-.............
Date
PermitNo........................................................ Issued-.......................................................
Da.,:
�r icy
No.. •----•-•--•-_...
----• _ Fxs................ _
9 THE COMMONWEALTH OF MASSACHUSETTS '
BOARD OF HEALTH
F
. �` J�
Appliration for Disposal Works Tonntrur#inn romit
Application is hereby made fort a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
............:! 'm.?} t 1 - +U......................
... f.I / r ry iz.;�s
••t Location ddress -
n ( ^ 9/ ) 1•/t J7� \;P� ••! (J� d the A& O'e.'A/ s �..lo ALot o.
.... -_ !Owner ram? :•!Fla e t =:.N.... .......................................................
W ..... i. _�i .. . PV lC�s ddress ..r
14
Installer re-
e of Building =°naareis
T r
YP g Size Lot............................Sq. feet
a Dwelling—No. of Bedrooms.....!.................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ... ..............
-----------
___-•-••--•-
W Design Flow........;!5.5 . ..................gallons per person�er day. Total daily flow....... :. ...................gallons.
Septic Tank�Liquid capacity `Q4V-: allons Length.. -_.:�._.. Width...A!/_. Diameter_:_.. Depth.........:......
g g p
I Disposal Trench—.No.............`...�. Width.................... Totah Length,.................... Total leaching area........... ft.
3 Seepage Pit No..._�......._....... Diameter...._/. �.: :.._ Depth below inlet..._1 ?...._... Total leaching area..................sq. ft.
Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. L...............minutes per inch Depth of Test Pit.................... Depths to ground water........................
fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 P1 ................................................._................................. .........................................................................
Description of Soil...................................................................................................................................
....
x
W ........•••--•-----••........•••-•••••----------------•••-•--•-...--•-•------••--•---• --••- . --.....-•--....------••---------------•.......-----.._.......----................................................
UNature of Repairs or Alterations—Answer when applicable._...._ (<✓_ 7�7L�....---,7 . / .................n 11�'A/ ,
MO.A.' 4-
Agreement: r
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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
Signed
Date
Application Approved By..... ••-•�!-:_ ....: :` ..._...-•-•-----•---•--
y
Application Disapproved for the following reasons:.............-.............----•---•-------•--•------------•......------••-•---••••-•_..._ Date.......-_---•-
s
...................................................................................................-.................................................................--•-•--•--•---••••---- •••......---
Date
PermitNo......................................................... Issued_............................................._•........
Date
F
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH r
/L
..............r........................OF........
����'r�.�................
Trdifiratr of Toutpliatur
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------/ `Z -7 r�cv.�y & ? /�/r' — 710✓
A L'Installer
-•-•--------------------------------------------___.........•-----------
/4 "1/�d�,�i
at.. ......-•-•••..........._ / P�,�ri vC
has been installed in accordance with the provisions of TITILF 5 f Th State Sanitary Code as described in the
application for Disposal Works Construction Permit No. ...%1_.:_._/v�_.�.__.._._. dated_--....._... ' � �l" FJ_
--------------------•---•-- ..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTf UE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................
� •-•'� Inspector. �� ..�.. ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF...........
No.......................... FEE........................
Disposal Vorks (Ilkonntrnrtion Pmmit
Permissito Construct on is or Repair hereby
Re granted
nted.- �
-•------••-=. .----
( ) p ( "�an Indivi 3ua1 Sewage Disposal, .5vst�em`
atNo..-- •--•••. ...................................................---------------------------- -----------------------••---- -•--------------•....._..._---•...
Street 1)/0)7 / `�-
as shown on the application for Disposal Works Construction Permit No_____________f Dated-_____._.-.'._� .;: , �5
f .....................
......................................................
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