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LO `CAT• 10 SEWAGE PERMIT NO.
VILLAGE
I N S T A LIC
R'S NAM i ADDRESS
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/Z,;.,¢t/ 2�y, o�lom 11-d
OR OWNER
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DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED _
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THE COMMONWEALTH OF MASSACHUSETTS
�- BOARD OF HEALTH
..........OF........... Iz. f.A. .�i ........
ApplirFation for Disposal Workii Toustrnrtion runfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.....
Loca...C,2&A� 1.4.
Address t
Owner Ad ress y��f
w /fe
....... ------------------------------------------------
Installer Address
Type of Building Size Lot_
. feet
aDwelling—No. of Bedrooms........................... ...............Expansio Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons..... ....__.___. Showers ( f) — Cafeteria ( )
Otherfixtures -----•------------------•------•-•-•------------•----...---------------------•---------------•----=--••-------------------------••------•-.........••.
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W. Septic Tank—Liquid'capacity.........._.gallons Length................ Width................ Diameter................ Depth..................
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) DosinY- ank )
'-' Percolation Test Results Performed b [ ' ..�?-VA2.1-.�t_-�,�_:. Date_._
W -- ----- -
a Test Pit No. 1.4<. .�inutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2_ .__ minutes per inch Depth of Test Pit.................... Depth to ground water........................
------..-.
O Description o S Cj / C?j}ly:#` Q. s�5 C- I - -�-GC3''�'1�
q �y � ._
W
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
------•--•-•-------•---•--..._••---•------------•••-•---•----------••-•--•-----------•-----------------•--•-...•-------------------•-----••....------••••-•-----------------------------..........------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n ' s yed by the bo d of ie t /
Sign .. .�..._-----• .. ••. :. -------•---- .....
Dat
Application Approved By........ K•.` ... `-•--- • i � ..r ..... ............
Date
Application Disapproved for the following reasons--------------------------------•----•----------------------•--•-•---------------------------------.....---------
.. ... . ........ .... ..... ..........•-----•-••-•--------••.....-----•-•------------•-----------•---•-••........................................................ .................
(� `Date
Permit No......................................................... Issued-------{ C/d/
No.._........ Ii ._ ........................_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.,e;. . .........OF.......... � A6.: ...........
AvOirathi t-'fitx Diapasal Works (f.unstrurtilin ramit
Application-is. ereby.made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-.- -
oca Address
W / Owner ress
a _____•--•..... .................
Installer Address
Type of Building Size Lot......... q. feet
Dwelling—No. of Bedrooms............................................ExpansipAttic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons....__.__._:______.___:..._. Showers ) — Cafeteria ( )
Otherfixtures .........----•-•.............•--------•-.................--..........._.
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 ( ) Dosin ank ( ) `_
f� J
a Percolation Test Results Performed by.: �"�- t _Ail I`l1� -... Date--�� .....
Test Pit No. 1 minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2. __ minutes per inch Depth of Test Pit.......:............ Depth to ground water........................
---------------------------------------
------------------------
4, 1-ohk,.: , V, .
ption
f S
O Descr><it oi. �............. ' ,,.
f * ►
W
UNature of Repairs or Alterations—Answer when applicable..........................................:..... :.............................................
.............•---••---...-•-------------------...---••---------......----------•-----••-----•..........------••---
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code—The undersigned rther agrees not to place the system in
operation until a Certificate of Compliance has b n ed by the b d of 1
Sig d _
Application Approved By.... = �'�'" �..-..................• ----• ;"� �' "..-....
! Date
Application Disapproved for the following reasons:-------••-----••................•-•---------•--------------......----------.._....-----••-•---....----•...------
........---••--••-•--•..................•-.........-••---•----••----•-----........---••---•--•-----....--••------..............-•---...-----•-------••-----•••--------•••-•------••••--••...•---•-__--•-
Date
PermitNo....................•----••-------------...----=........ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. . .. .....OF... rp.t.... / ;.....r.......
Tatifirttft, of ffilutplitturr
THIS, IS C TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...... 1....._. • l, . ------_... .................. ..........---••............-_-__--___.........._.._..........
..-
// Ins alter
at... °0.{ lr .... :, .k►f wle�e!..... .......................................................................................
has been installed in accordance with the provisions of he State Sanitary C de as de rJ'�ed in the
application for Disposal Works Construction Permit No. __ _.__ —2•—�"'
- � --�.............. dated......
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM LLOFON SATISFACTORY.
DATE [-y,%�.......... . Inspector-------•---F ..
- - ---••-
THE COMMONWEALTH OF MASSACHUSETTS
1 BOARD OF HEALTH 4
/ .. ...OF O F....., � � .....................
�'lJ
Permission is hereby granted ..
to Construct ) or Repair ( a Indivld al Sewage Disposal System
at No.J.4..( { !'1 ._ :/ C ',,. �F. --.....--•--
Street
as shown on the application for Disposal Works Construction Pe i No..... ........ . Dated.....�''2
--• .........................
/�_ Board of Heaith t
DATE......... .... ................. !.........--••-•------•--•-----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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