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LOCATION SEWAGE PERMIT NO.
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V I L L A G E
INSTA LLER'S NAME i ADDRESS
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e U I L D E R OR OWNER
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DATE PERMIT ISSUED 2 3 •_ 7
DATE COMPLIANCE ISSUED
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_ //N,CETU/STR%�llT/ON BOX •O FT c GRDUNU, W,�ITER TABLE
` OUTL�ETD/STRIBf/T/UN BOX g 5.`� F7 = SECT/O/V OF.
INLET I -ACN7NG /�/T S.5 FT. .5-EW-14GH _.DOSAZ'OS/4 J SY.STE/Y! F
LEACH//VG . �/T 7�BUL.AT/ON
DE3/GN •Cf�/TE/�/� .-SCALE UIMENS17N A 3 FT ;
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RESULTS lV/TNESSEp 8Y T C� nid S<.f s
607TUMLEygCH/NG JaLCR p/T 4 =PCWCOLAT/ON RATE /N�/NCH
TOTAL LEAG'N//YG AREA 2(o SQ, FT S s3 S o!L Sv/3 S a r /�E,�COL�17"/ON R.47"E� F��
RESER1iEGEAC'NINGAREf�
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THE C OM MO NN.W....E...A. L.T. .W OF-WnSSACHU
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Aa for Dhipaaat-Vorkii Ton.6trurtion Prrmit
Ap lira ' n is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
/ Sy tem at: ---...--••--•--•--•---••----•••. ...... ......
V/ .......... ..e....... ................
j� "S d or Lot No. ...
I. ... ......... .....
n Address
...............................
Installer Address
4 Type e of Building,,- Size Lot../j � ••-•---.-Sq. feet
Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ......................................................
-
d
W Design Flow............ .. .
_ allons per person per day. Total daily flow.........____.__..___.:..
...................gallons.
WSeptic Tank -Liquid capacitylp '' '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._ _.��
Z Other Distribution box ( ) Dosing to ( ) -
`" Percolation Test Results Performed by.___.. •G�ta•� - .:.................. Date___l�_`_._ �._�_ ......__..
aTest Pit No. 1----s_�minutes per inch Depth of Test Pit.................... Depth to ground water........................
G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--____-_---_-___--_____-
O Description of Soil-• •
U
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 1Ii ." y g g p y
5 of the State Sanitary Code— The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sign( ....... •-•••-••-••-......•-•••---••-•••••••-•-•--••-•-••-•--•......••••-• ................................
Date
Application Approved BY 1 •... •• ..... .••• 4 ...............
Date
Application Disapproved for the following reasons:................................7....................... R ,4,
•--------•----•------------------------------•--•-••--------......--•----------•--------------------•-....._..-•------------------------------------••-- ------------------- _ : -------------.--------
Date
Permit No.................•--•---••••.....•... Issued-../.+-��'` ---------- --------
Date
i
No� - FEE............... y.
THE COMMONWEALTH*OF "SSACHUSETTS ti
BOARD OF SALT
OF.....-. t; ....-..
• pphratilan for UhgVvii ai• nrhi Tnnitrnrtinn Prrmit
t
ApTlica on is hereby made fo a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
ep
Sy........
... .... _- ... ... .................................. .. .........- ---------------•--•--------
.op r s p .. Lot No.
awn - Address----- -•--••--•-••--••••-•--•-••---•----•...............•-•--...... ......... ....___.......--•---
Installer Address
U Type of.Buildm /- Size Lot__/1/.. ----Sq. e
�. Dwelling- nder No:.of Bedrooms............................................Expansion Attic ( ) Garbage Gri (
Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures -------------------•-. . ._
Design Flow. .......... ..............__/. allons per person per day. Total daily flow____------ .._.....:_.................gallons.
w q P 1. - ...g g ---- P
w : •--- a --- Depth
--- --•` .
x P ------- g leaching area------ q. ft.
Septic an �> m ca ac>ty_ a gallons Length Width________________ Diameter
Disposal Trench—'�To.�______________ Width__ _ Total Length-- Total leachi
3 Seepage Pit No.... .............. D>ameter_._... _... Depth belo inlet ._.f?._..._.... Total leaching area...... ft.
z Other Distribution box ( ) Dosing to ( ) c�
Percolation Test Results' Performed by-. _f .: :. :........................ Date___ ..................l-�...__..
a -----
Test Pit No. 1.__. minutes per inch .Depth of Test Pit.................... Depth to ground water-___--___---___----____-
G� Test Pit No. 2................minutes per inch Depth of Test Pit...___....._______._ Depth to ground water..... .____-
�` `�-
-----
O Description of Soil a `° �`� `�' r' ��- '� i `�`a..-••-�- �''--
c,
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 T TLE
p 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.
S>gne X
......................... ................................
1 to
Application Approved B - . --------•----
PP PP Y Date
Application Disapproved for the following reasons: ----- --- ' ------------------------------------
-•••••-••••••-••••-•-•--......---••-••-••-•-••••-•••--•------•-••-•--•-•--•----•........--•-••--••••••--•-••-•--••--•••••--••-•-•--...-•••-•---••-•••----- =------------------------------•----•---
Date
PermitNow...................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
.......... ...... `'r ...OF...........- °r.......................................
t
C�rrti�irtttr ,af f��ant��a�anre
T I S TO ER Y. hat the Inu vidual Se zge Disposa System constructed ( ) or Repaired ( )
by .;, aaeaaaacre ... .......................------------- •....----L................ X.
���y�i taller. "" !/
at. r�'� .44
r,4,
has been installed in accordance with the provisions of j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ....... .._..__.. ...... dated.... � ___!'',.. .--_---•---.
THE ISSUANCE OF`TH IS.CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..............1` a ---....._.. Inspector
...--. -_ ---•-........... L'!
------------------------
t
THE COMMONWEALTH OF MASSACHUSETTS
<" BOARD }0 HEALTH
N t�.a,. FEE.—
......................
wilipos al orrk n tr rtilan ramit
Permission i 'granted ..................•.--- ---.................
to Constrt (, �ro Repair ( ) an I du SSewage s o st ' �,.
at No...... r/ . :.:, ' ✓ ---- .... ...... ....... •--- ..........................................
-------- ----- -----•...............
Street
as shown on the application for Disposal Works Construction Pe. o.___.. 7.�� .
o/ - '�
Board of Health
DATE.. .... d `
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS '