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MADE IN USA
Aot—CATION S E AGE PERMIT NO.
V,I L L AVr
I N S T ALER'S NAME & ADDRES'S' '
B U 1*L D E R OR OWNER
DAT PE,R.M'IY ISSUED
DATE COMPLIANCE ISSUED
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No.0 ur-�T Fsic......... ....�......
'THE COMMONWEALTH OF MASSACHUSETTS
BOARD O WEALTH
ello�, - ....OF........... ..C� ./ ..iI...... . . ...._............._.......--- .......
Appliration -fear Ditipagat Works Towitrurtion Vrrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...... ............... W- To 10 0
Location-Ad)jress Lot No.-VIp
41 ....
ner Address
W ......•..... N .0................•... ••---------•••------------------•--•••-------•---•••••------------._._...----•--•---------•••••--
' #.Staller Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms------------ Z-------------- - -----Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
G4 Other fixtures � e.--_-------.---_------------------- � ---------------Flow---------------- flow------
WSeptic Tank—Liquid capacity-Gallons Length---------------- Width................ Diameter---------------- Depth---------------- -
x Disposal Trench—No_________________--- Width-------------------- Total Length-------------------- Total leaching area-------------.------sq. ft.
Seepage Pit No.__ Q __.' Diameter_ ] _A below/inlet-_-___............. Tot lea ing area....3-Od.sq. ft.
z Other Distribution box ( ) Dosing to k ( Q/�- j- /a
Percolation Test Results Performed by......_- ._ .- �. ._ �.. . Date 1 '_77 -----------
Test Pit No. L _. -__.-minutes per mch epth of Pest it____________________ Depth to ground water_____.._..__.__..._..__.
G=., Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water---------------.--------
---------
1 ,.. . ----- -- f 2, - --- ------ •-
Description of Soil------V--"---� fit `-------�-- � J ram"`����
_ ..1r-
- -I- - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 been issued by the board of health.
Signed- l!�/l �• r-
- ------------ -----------------
APPhcatton Approved BY -- --------- y� �'-_1 ._�..
l Date
Application Disapproved for the following reasons------------------------••-----••-------•-------•-------•------•----•---------------_------••--•--------------------_-- ------------------------
•------•----••----•----•-•-•--•-•--••-----•---------•-------.................................................-._-------•-------••--•--•-•--------•-----------.---------
I Date -
PermitNo......................................................... Issued....... J A------�---.--•-----------
Date
�� - - --►�....���.�.�. ��..�................ ------------- --- -
% .......... ......."y..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0F........... .........................................................
Applirtttion -for Uiii oottl Works Tontitrurtion Prrutit
Application is hereby made for a Permit to Construct -( ) or Repair ( ) an Individual Sewage Disposal
System)at:
......... .. % . w.. .. �.. . .......................................... /__//------------•------------•------
Location-Address or Lot No.
r ,. /. u,, ; t , . . , r
-----•---------------------------------------•-' •-----. ......•-----••-•--•...... •--••--•-•-•--• ----•---•--------•--•••-------•---••............... ....-•----................................
Owner ' Address
W
Installer Address
Q Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms------------ ___---------------------Expansion Attic ( ) Garbage Grinder ( )
1:1.4 Other—Type of Building -----_--------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
QI Other fixtures ---------- -..'.....................
W Design Flow.....................��._.................gallons per person per day. Total daily flow_-_.__._......._.._-�'_L'_----------..__gallons.
9 Septic Tank—Liquid capacitv_�''-_'__gallons Length---------------- Width.._-____-_.-._ Diameter................ Depth------
xDisposal Trench—No- ____________________ Width-_-----.._-_--.___-- Total Length._.---___-__---__-.- Total leaching area-------------..-----sq. ft.
Seepage Pit No--------------------- Diameter______:_--'__'_�Depthfbelow inlet..................... Total leaching area----- -sq. it.
z Other Distribution box ( ) Dosing tank ( ) r - % r% 7
a Percolation Test Results Performed b j.... ._____-- ________ Date... -!.------------------_.____..
,a Test Pit No. 1_ ------minutes per inch Depth of Test Pit___________________ Depth to ground water...-------.---..--.___-.
(i Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-..---_.------_-----....
R; '
D Description of Soil------ -----;-----_= ... ry S`=� -- /_ " /_0 ,.,:4� ,(emu,r�J
---------------------------------------------------------••--
x +
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 Article YI 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.
\ l
Signed c fi r
-
--------- ................................
i.♦ ��t i Date
Application Approved B _ ----_=-�--------------- --.-__# .�lJ'luy-------�- -----/i--------7.7-
y —�----------------Date
Application Disapproved for the following reasons---------------------------------------------•_
-------------•----------------------------•--•------•---------------•--...--•---•-----•---•---------•---.-------•--------------•----•---------------------------------------------------•---------.-----
Date
fPermit No......................................................... Issued----_--------------- ---------------------•---•-------
» Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' 1
....................'.....................OF......................................-..........:..............---.................
Cprrtif irttte of Toutplitturr �,,
THIS,IS TO CERTIFY, That the Individual SeZ11j"'
is 1 Svst constructed ( ) or Repaired
bd`.. . ------- --------------- -
I /
at---- ---------------------------•-------------•-•--•--- ....------......----••----------------- •-•-•-. ..........- I r_ _( .......••-•..................................
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
11
application for Disposal Works Construction Permit No r 1_..'_•_ __ ________________ dated._.._-__ -_-.__7. .______._..._._._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
} e ..........................................OF........................................I.. -- -•............................... 6. 3
NO.........-•-----•- FEE.
i� o tt o T iitrurtion "rrutit
Permission is hereby granted --• ----------------------------------------------------------------•---.-----
r
to Construct ( ),. or Repair ( ) an Indivi ual Sewage b�' OJ�al System ,
� ,
at No. = - f
........= r
Street
as shown on the application for Disposal Works Construction Permit No--------------------- Dated-----4-'_& � .............
, ,- ,r
Board of Health
DATE---•----------------------------------------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
_9 5 G.17TD.
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