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LOCATION SEWAGE PEANIT NO•
VILLAGE
INSTALLER'S NAME i ADDRESS
BUILDAFR —7
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DATE PERMIT ISSUED
DATE C 0 M P L I A N C E ISSUED
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No........'--..79..... Fes$. �4r.............
THE COMMONWEALTH.OF MASSACHUSE77S
BOAR® OF HEALTH
.-•................ OWn....oF.... �zrr, ,r�,b1 ...... ... ........
Appliration for Uiipnsal Marks Cnonstrnrtinn Urrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( >() an Individual Sewage Disposal
System at
LaO
• ......---••-•-----. ---••...............•---...........----••.
ion-.A- r ss Lot No or
.....� 1��.101'C ......... .........................••---.....: ......... } C�Y� d. ........................................................
� rn Owner
. n;, . •---..._G�'n vi) ads...........................................
M Installer Address
U Type of Building Size Lot............................Sq. feet
U`4 Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers
t� YP g ---------•------------------ P ( ) — Cafeteria ( )
04 1, Other fixtures ...........................................................
Design Flow............................................gallons per person per day. Total daily.flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
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 ( )
aPercolation Test Results Performed by........................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.--...........--...----.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x ---- ---------- -- ........... ... _
- ^ I
0 Description of Soil �- •• •�j lu ----------------------------------•-•--------- ----------••-------..................................
V .................•••••••••-••••-••••--•------•••••---•••-•••-•••._.........••••••-•-••..........................••••••••.....-••••--•••-••••••-•••--••-•••-•-•-••••••-•-••-•-•-••-••--•••......-•-•--••.
W
U Nature of Repairs or Alterations—Answer when applicable.....1 P� ------------------------------------------------------
..••-••.....-•••---•••••••••••-----•-••---•-•••-•••-•-••••....•••-•-•••••-•••••••-••---•-.......•-• ••••••••••-•---•••-•••--••-•-••••••--•-••••••••---••-•••••-••--•••-•--•--•.........................
Agreement:
The undersigned agrees to install the aforedescribed Individual.Sewage Disposal System in accordance with
the provisions of TIli U 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.,
�,�/� G
Sign e ••••.... * •-•-••• l�C(1 � 1 -•� .-'`1s0_
Date
Application Approved By.......... --•••- .......
Date
Application Disapproved for the following reasons:----------- •---------•--------•----•--...--•---------------------------•------•------........................•-
......................................................-.....................................................•-••-•...•••••-•--•••••••••-••-••••••••-•-••••••••••-••••••••...........-•••••......--•-----
Date
Permit No......................................................... Issued.......................................................
--••-.. -•--------
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
.. ...:-........... ........OF. r.. ' ... ...., ..
ApplirFation for Bispos al iirkii C9nntrnr#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ,Y) an Individual Sewage Disposal
System at:
1
................_.....--.....----......-• ••= .. ...................... --••-------------._...............------------.............------...............................--
1 —Location-Address + or Lot No.
---------------_:_:_.J_..�..1.-- t• .............................................. .............. .. .. ..._ f' ......`...`. .... .... ........................................-.....
Owner fAddress
a ..............................................1?tter. i . ---------•--......._�............. /...--•......................•-------------.-----
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures -----•-•-•-------------•---••-•. .
WDesign 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..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
'NPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
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 TITS 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.
Signe f
,! D e
Application Approved By-•...--_/�,- E: .......Aa........................
Date
Application Disapproved for the following reasons:................................................................................................................
...................................................... ......................................................... ............. -----•••--..._
Date
PermitNo......................................... -- Issued-.----.................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF"HEALTH
....... O F...................................................... :.:.,..
(grrtifiratr .of Toutplian
THIS IS TO CERTIFY, That thejrldividual Sewage Disposal System constructed 1;. ) or Repaired (-,)
r .
by......................................................
Y=
Installer
at.............................................................. ---•••--- °1 ..•---- ., --•- ------------. s.
has been installed in accordance with the provlsions of 5° 5 of The State Sanitary Code as des ibed in the
application for Disposal Works Construction Permit No.- -- y7- -'......... dated_... s�.`..�.' p
THE ISSUANCE O0\THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATI•SACTORY. �
DATE. � � D Inspector-— �! ,l'Y'
.. ..
AZNr*,3. .-zip, et •K' 'y�..;i,n�." i .
''�`:�' :�w'�ti�� �E�,at�."' '�+'�• THE COMMONWEALTH 'OF MASSACHUSETTS y
BOARD OF HEALTH
...... f t f..j.......OF....�....:..:..' /::..../ I :.��_. 4` .................. ifs
�f ..... .... .... ...... ......... J ..� 1�
No........... ....:". FEE..........:..:..........
�a �t1rk . Cnnrttruan prntt#
Permis$ion is hereby granted ._: . _ ........
to Constructz-, or,Repair � •(;,M) p ( )F.an-Individual-Sewage Disposal System
at No '
Street � �+ /► �/r
as shown on the application for Disposal Works Construction�epo.._i. �Dated......�....~......`......._'..............._..
._..
n: Board of Health
DATE.-----Id •......................•----•--.....
FORM 1255 Hoess & WARREN, INC. PUBLISHERS ,.ems