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LOCATION : 4' f SE\NW:aE PERMIT UO.
VILLAG
IPIST L RS .DDRE
BUILDER 5 Q &VAF— ADDRESS
DATE PERK"AIT ISSUED — — —
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Robert 1-4. J0/-7
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF H- -EAA—L�T�H�
d'�-r01 t O F. GL40.20 �-a e'�""Y_--- ----------- ..I...�.
ApplYPatYLtYY for BYapuiittl Worbi owi#r1YY`fYoYT Vrrnift
Application is hereby made for a Permit to Construct ( or Repair ( ) an In 'vidual Sewage Disposal
System at
......02......... ----------------- _6c... J��
cati Add ss or Lo No.
----- --- ---- - .....................................
Wrier A dr s
nstaller Address
Type of Building/ Size Lot----------------------------Sq. feet
U Dwelling No. of Bedrooms.............................. .............Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building -._.-_--------- --------- No. of persons.--__---.-----------_---.-_ Showers ( ) — Cafeteria ( )
Q' Other fixtures ---- ------------
d .................
W Design Flow-------------------- ----_---_ 111ons per person per day. Total daily flow..........Gv`...... -•-_-__-__----.----_._._gallons.
WSeptic Tank.4—Liquid capacity/ allons Length________________ Width................ Diameter---------------- Deptli__._-.--:_....--
x Disposal Trench—No ____________________ Widtlt..._..... .__.__ OaLe ham_... . . ..� Total leaching area.__.___.__._...___._sq. ft.
Seepage Pit No........ ......... Diameter_ __ e . in el-t. .._-�-. Total leaching area....-------------.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by..........................................................:. . ... ... Date-------------.--_--_-_-.._ _
a Test Pit No. I----------------minutes per inch Depth of :Pest Pit-------------------- Depth to ground water-----.1- --.-_---_._.
(� Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground
water---_-.--------__-..._.
9 _ ._
Description of Soil-..'.__
------ ----------------- �' J
x
--------------------------------------
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V 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 Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has issued by the board of health.
igne --------_----•-- •...............................
ate
Application Approved BY r.
............. � :
Date
Application Disapproved for the following reasons:-----------------------------------------------------.•-•------------------ .....................................
............................•-------------••...........-------•--••------••••---•----....--------•----------------------•••-----••....-•---•--••---------•-----•-------.......---------•----•-••--
Permit No........................................ Issued. _ .., te
'�a.. ... ....%L ...
Date,/
... .........—--------------------......-----_)---.---------------------9----
NO.----•!'-.TAI•-_. Fas...Id...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.�.
Applirtttinn -f ttr Di-s niitt1 luorks lani#rurtion Vrruift
t
Application is hereby made for a Permit to Construct ( ' or Rep {r ( ', )''an In idual Sewage Disposal
System att�704;,?e
w
cats Add ss 414 /� r Lo 'o.
wner A t
nstaller Address
Q Type:of Building, F Size Lot............................Sq. feet
U Dwelling , No. of Bedrooms______________:__--___--:--__,_-____--_-__-Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons._-,.._----_______----_-_:__ Showers ( ) — Cafeteria ( )
a' Other fixtures .._ _ }
Design Flow _____-___-___-__ ... Mons per person per day. Total daily flow.......:.......0" _-____.-.--..._:gallons.
W Septic Tank�Liquid capacity/4�allons Length---------------- Width-.-__-.--.._.-.. Diameter-----.---------_ Depth...-.-.--.----.-
~• ..
x Disposal Trench :—No ____________________ Width._._._...______ to Le i ____ _ .. Total leaching area--------------------sq. ft..
See age Pit No..______ ___________ Diameter_ e b p g ,/tom_.�fo. Inle :.....________....r'. Total leachilg area____...__.____..sq. it.
z other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Perfolmed 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----------------------
------- ._-
Description of Soil._' --- .........
U ------•--------------------•-----------------------•-••--•--•-- -----•-----.....•••••••••-•------•-•-•-•-•••--------••-----•••••......------------------•-,----
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 Article \I of the State Sanitary. Code— The undersigned further agrees not to place the system',in
operation until a Certificate of Compliance has issued by the board of health.
'igne + ._ ............. _ .
Application Approved BY-------- ...... - . ............. .
Application Disapproved for the following reasons-....................----t+� ate
-------------------------.----------------------------------------------------------- ---
•------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------`
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
. 1 ^...............OF...... aAv..h..............................................
r ifirtt#r of TOMptittnrr
THIS O CB TI hat, ndividual Sewage Disposal.S stem onstructed + or Repaired
( p
b ,r
�. °"tl0 .v.-• • Installer
,
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--- -_----. .....
has been installed in accordance with the provisions of Article YLj of The tate Sanitary Cod a descr bed i the
application for Disposal Works Construction Permit No._...........1.7--. _ dated........ ....'I...........�'.............:. f
E ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GY4RANTEE THAT THE,
SYSTEM Val LL UNCTI SAT SFACTORY.
is � �k -
Inspector J�
Dt1TL .. .
. ------•--------------•--- -
THE COMMONWEALTH`OF MASSACHUSETTS
BOARD OF . HEALTH
• OF . - .
FEE -(-/
--•---•_•-•^....
i n tt1 nn #.r r atrrrmit
a Permission-- s reby granted... -• -•-------•--••---- ------------•--•• '
to Constr t r air ndi dua wage �oral System
4 .
at No. R ( g p Y kC .............•-••-••••-
-,.Street � � (-
as shown on the application for Disposal orks Construction Pe > No_____ _______ __ � ed.......�_i.�/' 7�- ......... �
---- --- -- -- - - -- -• ----• -- -
oard of Heal
<� DATE.............................................
FORM 1255 HOBes & WARREN. INC.. PUBLISHERS ,