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L C&TI P 5EW6,C�E PERMIT UO.
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DATE COMPLI &MCE ISSUED :
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THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH a-36 -06/
'B ..._..............OF.... ✓P ✓ A .G..............
....-..........
Apli iratiuu -fur Mapwial Workii Chun rtuin Vantit
Application is hereby made for a Permit to Construct ( ) o Repair ) Individual Sewage Disposal
System at:
- _u/.-4�z-'--------------------------------------- ---------------------------------------------
Location A dress / •t No.
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W 4AQ Owner e[`{► Address ��
f•••I ��![ -------------------------------------------------- ••� 6! _ "VL-- -�����
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.3'".................................Expansion Attic ( ) Garbage Grinder ( )
Other—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 �_&a.._ Diameter____________________ Depth below inlet.................... Total leaching area.-..___.-__.--____sq. ft.
Z Other Distribution box.( ) Dosing tank ( )
Percolation Test Results Performed by.......................................•___-----------••••-•••-••-•••••--- Date------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground:water...__-_..___._--_.:.
riq Test Pit No. 2................minutes per inch Depth of Test Pit..____-______-_____- Depth to ground water_-._..-_--_-_._____--. -
�' ..-•-------•------------------------------------••-•-...---•--------•••--•-•--•-•---•._.._..------•...........................................................
0 Description of Soil__ --------- e A/' ---------------------------------------------------------------------------------------------------------
x
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 XI of the State Sanitary Cod The and igned further agrees not tL11ace he system in
operation until a Certificate of Compliance III
s ss
Signe the of health.
F ------------------••---•-------
Date
ApplicationApproved By------------ ------------------------------------------------------------------------------------ -------•--....-._.... . ----------------
Date
Application Disapproved for the following reasons:-------•----------•-----------------------------•......•--------•----•-•-•---•--_----........_---------------•--
..-•--•-•---------------•-----_._..---....--------._-_...----•--------•--._..._._..-•---•-----•--•-••-•-•------------•-•-•-----•---• -------•---._.--- --------•....•.----------•---
�/ Date
PermitNo........................................................ Issued...... v -- -----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
OAR® OF HEALTH
40 .....
Appliratinn -fur Dispagal Works Tort #ton �rrmi#
1.Application is hereby made for a Permit to Construct ( ) o Repair Individuaf"'Sewage Disposal
System at .
caf drens,a..,:./ t No
.40
WFy Owner �Q }� �/
a -^-' .._.� .9=rt• ----- ------------------------------------------ i!! _. ``Jr '.��'• •,L: res
e�
Installer / Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms_0200........................:.........Expansion Attic,( ) Garbage Grinder ( )
04 Other—Type of Building --_:.-..-.--_-_------------ No. of persons____________________________ _Showers ( ) — Cafeteria ( )
Q' Other fixtures
W Design Flow____________ ____________________________gallons per person per day. Total daily flow--------------------------------------------
9 Septic 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 trea __--.--.----_____sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by. _____......... ..........-..__._._..._._....__ .____:_. Date--_-------------------------
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--.-..-_-----.----
a _---- -- •• ---•-••-•-----------------------•••- .........................................................
G Description of Soil..., _:_..._
A"'--
x ..
O .-----------------------•-•-----------------------__-_..-_.._.----•--------•----=--••--•-••------...._._..-•--•-....--n'`'=•------------------------------------------------------------------I-----------
W L
------------------------------------------------ ----------------...........................
-•-. ---- --- ---- •---• ----
U Nature of Repairs or Alterations—Answer when applicable
.
U P' , ,"
------------------------------------------------------------------------------------------------------- = " ------- - ' - ---------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Cod The and igned further agrees not to lace the system in
operation until a Certificate of Compliance h the r f health.
e�
Signe --• - --------'--------' •. . • ..,pr
... _ Da;
Application Approved BY = ------------ -------------------------- -_-------._...-----------
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
• - -• Date-•
Permit No......................................................... Issued.-_ ........-----•
�Q ` a:. _'` 7
Date
3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFplvilp�haurr
TH
..........OF..................... .............................................
uIrr#ifiratr of
T 0 CER" , That th Individual Sewage Disposal System constructed or Re afire
by--•- ---•-•-• -- ------ - ------ ----- ---•-- --- ------
g P
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has been installed'in accordance with the provisions of Article XI1Qf The State Sanitary Code as described in the
application--for Disposal Works Construction Permit No ___________________ dated. .............._.._.._ .`s
THE ISSUANCE;"OF'THIS CERTIFICATE SHALL NO BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM W L FUNCTION SATISFACTORY
DATE_..-. --................................................... ---------- Inspector---- ----------------------- -- ---------------------------•-----------------
1o, THE COMMONWEALTH OF MASSACHUSETTS
BOARD/9F HEALTH
4
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.. . .: t.........- ------------•.................. .'0 . -� . .. ..
-•- -- '. FEE ,�-.-._.
�i� >att C #r>xr#i>�itrr�ti#
Permission is herebyrant
g ..•..... ----- ------ --
to Constr(ct ( ) or Rep Individual Sew •e_.D-sposal tem •- i
at !9
y w Street
as shown on the application for Disposal Works Construction ?erp, : Dated.... -- -`- -- --- of Health
DATE
--
17------------
----•- -----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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SEWo.GE h/llT M0-
LChTI PER
V1LLhGE
1w NLLER S W&^AE ADDRESS ,I
5UIL®ER
- - - — —®N-'1= PERKA1T ISSUED '
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® Q.TE CO NAP LI &&ACE ISSUED
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