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LO CANON ilei ZaAl< SE *A 6 E PERMIT NO•.',
VILLAGE
INSTA LLER'S NAME i ADDRESS —
JOHN A. e4I9LTO BACKHOE SERVICE <'
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1 &msW% Mass. 02668.
IUILDEIt OR OWNER
WAI'ree 5el t
O-ATE PERMIT ISSUED
DATE COMPLIANCE ISSUED���� � ` 7T
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HFwALTH
............... .� ......................OF......................
.....:.......... �............._.
ApplirFatilan for Diipnoal Works Tunstxnr#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.............................. .............. ------------ ------------------.......----------
` L] attiion-Addsk s o�r '°t /'7�
O e ddres
Installer Address
Type of Building Size Lot.�.L' ......Sq. feet
�., Dwelling—No. of Bedrooms.._......._�.........................Expansion Attic -( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.......__._--•_------------- Showers Cafeteria ( )
d Other fixtures ------------------•----------- .......
•------------------------------------------•------------------•-----------------------
W Design Flow..... ..... gallons per person per day. Total daily flow...................._ _d..._....gallons.
WSeptic Tank—Liquid capacity, .D.QCaallons Length................ Width................ Diameter________-___.._- Depth................
x Disposal Trench—No..__.... ... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.—-�°_-__-. ameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing
aPercolation Test Results Performed by...... PO P>r�
a Test Pit No. L/_4....minutes per inch Depth of Test Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
./j.. • • •---••-•-......................
�O _ /qi / � 'Description of Soil. .. � . �
iff V
1! UW ••-••-••-------------------------•------•-•--•-......-•---•-----•---••-•-•-.._......•---•-••-•••....---••-----••......---------•...--•••----•-••----••---•-•------••---•-••••......-••••-•••............
Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement: IF,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu by the board of h tth.
Signed---- . ------/% %' ...............................
/4 ,\ Date--
ApplicationApproved By..... ------------------------------------•--....-•--•-•••-•-...••............-- •-•--••---...=-,?-U 1-F......
Date
Application Disapproved for the following reasons------------------•-------------•--------------------•---------•-------------•--•---------------••-•-•----•---•--
--•------•-----------------------------------•----------......--••---------....--•--•--•---•---------------............................................................
Date
_..._.. Issued._--
Perms No.- ..I y ---..z/....... ......•.
Date
- � F
ISO O
---..,I SS..... ... ............„
{ w. THE COMMONWEALTH'OF.;.MASSACHUSETTS
.. BOARD OF. '`F-I ALT1-1
� rlir #iiatt flanin �a1 ,ark C� t� ttr#i�an rani#
Application is hereby made for a Permit to Const ua °(,, ) or Repair' ( } an Individual Sewage Disposal
Sy
....
ion A¢ s or t No•f
Z Q cr,5" Y!�j_'�_?. A....................... .f ' ..!.C�p.._ S?. ` . `.:_.•---
a
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e!S
t. _ . .. _, ....._ --- --
P Installer Address �j
Type of Building Size Lot_ J...... `''1.......Sq. feet
Dwelling—No. of Bedrooms_____ ___ ____________ _..........Expansion Akttic ( ) Garbage Grinder ( )
Other,—Type' of Building ____________________________ No. of persons.......__._________.____.___ Showers-O — Cafeteria ( )
Oes . --- - -•------------------------------------------ •---- -------------------
W
Design Flow._.___ ______:..............; gallons per person per day. Total daily flow...-_.. ��.......................................
Design
WSeptic Tank—Liquid capacit: .9P$allons Length................ Width................ Diameter................ Depth................
Disposal Trench No. __ �¢ �__ Width___________________ Total Length.................... Total leaching area----_...............sq. ft.
��� ___..._ Depth below inlet____________________ Total leaching area.__.._________.___s ft.
Seepage Pit No.*'----- ----------- �ameter___._._--_--• p g q.
Z Other Distribution box ( ) g Dosin
Percolation Test Results Performed by..
!• !'� Da �'! '
a` Test Pit No. 1 _!q_._._minutes per inch Depth of Test Pit l'� ?. Depth to ground water________________
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
r --•---••.
............... ..... ___-------- - -
D Description of Soil.:._________ Q.. ...... �
x
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 TITLE 5 of the State Sanitary-Code—The undersigned further agrees not to place the system in
operation until aCertificate of Compliance has been issue ,by the board of he lth.
,
Signed...,,.' ...-- •--•..:................. .
/C Date
ApplicationApproved By--- "------ --- -•------------------•-••-•------...-•---------•-----....._................ ............. c 7� ,
Date
Application Disapproved for the following reasons________________________________________________________________________________________________________________
____
Date
r
PermitNo....../_�.�. ........................................ Issued.......................................................
p) Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............OF.................�y ....................................................
Trrtfftratr of Tourp.liattrr
.................
•--•- �- •� �-----ell
---•-•+----•--- --------- .System constructed ( ) or Repaired ( )
by THIS IS TO CERTI hat the vi 1 Sewage Disposal
�y�+
Ins �� .Lh✓l
at
has-been`%installed in accordance with the provisions of TITLE j of The State Sanitary Code as des ibed in the
application} for Disposal Works Construction Permit No.....-y_ ` `��_ _________________
THE 'ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................................................... ............ Inspector....................................................................................
THE COMMONWEALTH OF�MASSACHUSETTS
BOARD OF 1,JEALTH
.......`...t 'f ' .............OF.................... ...Q.}�....... ,7`.L!G:_..._._.._..........._.. —�
No......................... FEE... ::...---•--
Disposal lump Tjjgt iott remit
Permission is hereby granted ------.��P.. i--•----------------------------------------------------------------------------
to Construe�r�( or Repai (, n Individ S .wag Disposal System
............................................
Street
as shown on the application for Disposal Works Construction Permit No.__XfY.__.______ Dated.....�._ ............................
----------------------
Board of Health
�' /12_�y DATE-----•------ --��� ---------------------------•-------•-•--
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS � �
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�� �L D ff D E, ENGINEERING CO INC. ' w �`e
— I CERTIFY THAT THE `PROPOSED ; '
_ CLIENT '
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