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LOCATION SEWAGE PERMIT - NO.
V1 LTIWE
I N S T A LLER'S NAME i ADDRESS
GUILDER OR ' OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
Ale
it
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O} F HEALTH
E A L JT H
...Fowl?..........OF.... . .��.l. ..........................................
Appliraatiun for Uispaa al Workt Tunutrurttun rantit
Application is hereby made for a Permit to Construct ( ) or Repair (1-r an Individual Sewage Disposal
System at:
tion ddress or Lot No.
........ ..'.......�_} L' . ------------=---------------------- :? .1.. ..........................
O ner
�..e----------•--•-•------------•--------
a Installer Address
R�
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P'' 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. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� - Percolation Test Results Performed by-------------------------------------------------
•-------------
....
Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._.......:...........
_.-
P4 ----•• -----------------------
Cl
O Description of Soil...........S�.�� �ML .-----..............................-...............................................................
W
xT •---•-----•-------------
U Nature of Repairs or Alterations—Answer when applicable-------
/...... ,1: -------------------------------
-- ----------------------...............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TA IL1;;^ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has n issued by the board of health.
Signed.......u. ...
Date
Application Approved By...... ....... ---------•••--•-••--•-----•- -•-- Z Y'
Date
Application Disapproved for the following reasons----------------•---------•--•--•----•--•-----------•--------......---------------------------------------.....•-
.............•..----......-•----------------------------....-•------------•--•--•---•---•----•••••---------••..._..••---••-•------•-•-••-•--•---•--•••--•••----••-••-•-••-••••-•-•••---••...----......._
Date
Permit No................ Issued•-----....---------
--------------------•------......----•--• .......................................................
Date
.a Z.-_..�-1a Fps
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--..... w _ .......................................
Applira tiun for Uiipuuaal Works Tuntratr#ion .e mi#
Application is hereby made for a Permit to Construct ( ) or Repair (i--T an Individual Sewage Disposal
System at: _
..... ..� rf... ».! r°. � . ................................ ............................................ •-
..................--..... ......----
l
" 1 { Lc}ration Address / y or Lot No;el prs4_ ' E _ I.a� �.. .: F ' f'�¢"d .s�" ."�� `7 .*sf ...^•ja�,.
......ns. - ... s. ........................
5
j�' r/1 , r• ti r ONyner ✓ " �_...�... Address'
W si • 9 i e�ff.�as�iC.. .... P r f' lr_ d f r + ;� ', s
Installer Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons...::....................... Showers — Cafeteria
d Other fixtures ---•-••----•-••--•......-----•-- -
..... . . .. . .
W Design Flow............................................gallons per person per day. Total daily flow..........•...:..___......____......__......gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
xDisposal 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-__:_-__-____--. -----.
(% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-- -- -- . `----•---•--•------•-•----------------•--..........-•-•-•---•--------..•........----•-•-•-•--•----.....
�. F �l t / •r; � ' '--•--•-•------------------•-------------------------....---•----------------------•--------•---••----
O Description of Soil
FWi -•-----------------.----•---------•---•-•---._...•--------------------------•----------••--•-•...-•----•------•-- --- ••- - •-- -••-••-••••-••-•....---.------
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 TIT LE 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 .._._.. ........
Application Approved By-----.:=: ............................. . ..1 Z-.-- ....��------
........•... Date--•---........
Application Disapproved for the following reasons:.............................................................................
--•...............•-•-------...-•-•--------------.....---.......-••-•••--•-•---•-•----..........................------......------------------------------------........................................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..... :. w ............. ...
................................
%rrtifirtttr of ToutpliFanrr
THIS„IS.TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired )
7�r r.r � ,tom ,+. I s] ✓`} � r•r.F
..._a_..... ..................................................
Installer
has been installed in accordance with the provisions of TITL:: 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....&. °� /d............ dated................................................
THE ISSUANCE.OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
'L.. /I
DATE......-•---•-----•--......-•---•-•--•....................f..._.IL� �`- Inspector . ------.. ..............................
f
THE COMMONWEALTH OF MASSACHUSETTS 4
BOARD OF HEALTH
k ,
............ ....,. ...... ... �.....t�............. r as f r
No._ ............. FEE........................
�i��oo�1 ur�u �un�trnr�ion�. rrnt)i��n7,J
Permission is hereby granted ...........%€ .. ............................................................
to Constr}�ct ( )/or Repair ( an Individua Sewage Disposal System ,••, , f
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
DATE_ VY ........................ Board of Health
FORM 1255 HOBBS'& WARREN. INC., PUBLISHERS - '