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ASSESSOR'S MAP NO. PARCEL 1�9 "" /Z/-/-7 'N
LOCATIONS GE PERMIT NO.
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VILLAGE
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I N S T A LLER'S NAME . i ADDRESS
1. CRAIG MEDEIROS f'S014
78 LINDEN ST.
OAF OWNER
47
DATE PERMIT ISSUED 2-
DATE COMPLIANCE ISSUED �����
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ASSESSORS MAP NO--d
No.... P..IY. . Fim..... 0...`
PARCEL NO; d ��
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..................OF. 9 7....
. ..............
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Appliration for M_qp sal Works Towitrur ion rrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal _.
Systemat' ...t .............. •-•-----.. . ----.......-• -•--........
Locat Add s e or t
... ..�.......... -7v .. ..e •.......... kT:-A / ... --- --------------
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w r ess... -- .....
W i
Installer Address
Type of Buildin Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g --------------------•---•-•- P ( ) — 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.
3 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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.---.-.-__-_-_-_____-.
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
a ----- -----------"-----•----------------•---------.......------•----•--...---------..............................-..........................
0 Description of Soil--------- -----•-"-"-"•---------------------------•--------------------------•-----------------------""-"----------------------------------
".�
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"'jE
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.
Date
ApplicationApproved By...................... . ...-•-•-•------------------ -•-------- _.-.
Date
Application Disapproved for the following reasons:................................................................................................................
..---•-•--•----------•-------------------•-----------------"---------•-•"------------------•-"•------------------------••---•-•--•-•-------•---------•--------•----------•-------•---------•--------•••-
Date
Permit No.------..F.1 l �-LL��-------------- Issued_.................------------------•---•---------------
No.... Fkic....�.....01_............
�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Diipuuttl Works Tonutrugjiun rrrnttt .
Application is hereby made for a Permit to Construct ( ) or Repair (L ') an Individual Sewage Disposal
System at:
Location= Address f.-,1 or Lbt,N7o..•.„.,,_-_• ,1
.............. ..• ....- — .......... '-...... .... .......�.> :.. -��—=rf...... .................. ........•...................... �.
{ _ ` Ow�taer / Address f
Installer ' Address
d Type of Building] Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
G 1 Other fixtures ------------------------•----------••-••••......•.....
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic 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........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
=y••--------�----•-'---••••••-•-•••--•••.••••--•---••••••-•••--••........................:.........•---•-..................--••---•--------------
Description of Soil............... .:.: . . ....�.
W HIV----------------•----------- �- `j y .,' �_' � =`=== ;
�--r ,"W 1 p ^ `rr Y{
UNature of Repairs or Alterations—Answer when applicable.......................................�_z.._'e..1__. '':.._,r......: ' ..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TT+�1:u..,.a• 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. -
f !
Application Approved B ` �-..- e�•-�-�-_/
PP PP Y.._..-------•--...... .............•---••------ ---------- Date
Application Disapproved for the following reasons:........................................................ ....................................................
-•---•---••---------•-•----•-------•--•-•-•--••-•--•-•--••-••-----------------------------•--------------••••--...••-•--•------••-------------••-•--•-••-•-•-•••-•-•--••-----•-•••--•--••-••--......._
p� Date
PermitNo......... ` s ---------------------- Issued.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�rrtif srtttr of Toutpliatta
PHIS IS-TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
-
t�z t
by.._._.... ; •--...... ---�---------------------------------•--- - ----.------------.--------• -• -----....... -------
f > / Installer / r /'� x
at.... r, ..--•1..........._...._.......f.._.�.... .... `.....a� . d :. 1 a., w -- F� t 1 �(
has been installed.in accordance with the provisions of TIT'_. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___._. t...:' -I. V....... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
- .....................•••• Inspector---•--•..._........... .DATE.....-----•.......:........�..-... �� ..�-------•---._.._.........._..................
THE COMMONWEALTH OF MASSACHUSETTS
_ -- BOARD OF HEALTH -�
/ .,........................... Z _) .�. .,�
PTO...... = / L� FEE........................
�tu�u�ul: u�ku �unu�rion �eruti#
Permission is hereby granted::•" '"""..--.J---::-_.W '
-------------------------------------- ...........
Construct ( ) Dr Repair (, )y!aii Individ a' Sewage Disposal System
at No.. •••••--- ------ ----- _s r -
- - r - `==
Street �/
as shown on the application for Disposal Works Construction Permit No..Q _&yV.. Dated..........................................
.................................... ------•-•--------•----------------------•---•----
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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