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L O CATION S E AGE PERMIT NO.
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VILLAGE
INST LLER' N ME i ADDRESS
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• U I L 0 E R OR OWNER
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DATE fERMIT ISSUIED o
DAT E COMPLIANCE ISSUED
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No. �.....:.2'Z _ W F�$...:30.......... .
THE COMMONWEALTH OF MASSACHUSETTS
76 BOARD OF HEALTH
Ji1/A/......------OF.......U� ��/s.............L
Appliratiou for Uispnfial Works Towitrurtiun ramit
Application is hereby made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal
System at:
......--.................. .. -- ------ --- --------------------------------•---------
Location-Address or Lot
No
=0 72ZUs7. ._.... Zy�zXV6f-1 to G----.._..... ------•---•----••.................•--• ----------------.....---•-_...• - •••-- -V �•••1�---A-•--�.._.r..�-
. s
..! ......._
wner Address
W
nsta Address i `g
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.._........_-_____________________________Expansion Attic ( ) Garbage Grinder (-W)
Other—T e of Building ............................ No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures _________________________________ _
W Design Flow................ 5......................gallons per person per day. Total daily flow_._._:.___ '�d_____________________gallons.
WSeptic Tank—Liquid capacityJDOD_gallons Length._f�6�`____ Width___4 Diameter_¢"_`�__ ____ Depth__,5 ��_--
x Disposal Trench—No_ ____________________ Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------- Diameter-------6_......... Depth below inlet----- ...........
Total leaching area_.;?°o.....sq. ft.
Z Other Distribution box ( J ) Dosing tank ( )
~' Percolation Test Results Performed by------C_n_lz__-S ST_______________________________ Date_____`? -2 ...80..___._-.
Test Pit No. 1_._G__z---minutes per inch Depth of Test Pit_____-�Z.__.___ Depth to ground water..
fi Test Pit No. 2..C__Z__._minutes per inch Depth of Test Pit...._. Z Depth to ground waterer u^!.71f_e
M ----•------•-•••------------------••-•-•-•-•-••--•-•••-••----•-•--•-•---------•-•-----•-•--••-•-•_...........
O Description of Soil ---O-Z 2-� z-O-)q,,,___�__S�so«— D 2V�'
x ---•------•--•-- -----------------------�1z.... .' c- t c� s ._ :z 2 z%-viz..'.
W ---------------------------------- I_/-`_-/z --------'-=JG its--C!0-�,6 WI-117-5
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'TTL71, y g g p y
5 of the State Sanitary Code—The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signe :--=- -
Dat
Application Approved BY---•--' -
- J..-
Date
Application Disapproved for the following reasons________________________________________________________________________________________________________________
•---------•---•-•--------------------•---...-•-----•--------...--•---------...---•----•-•--•••-----
G, .......... Date
PermitNo......................................................... Issued_....-�....--...........` , � ------
Date
No.._......'2._.....,, ..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
76 wN
= ................._---------- --------OF.......'�!9�n/ST�IBC-..................................
. Applirtt#iou for Uiipntittl Works (fouitrnrtiun Prrutit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:
................dam ..............................................vrEbv ----------------------------------�d�- .3
�.y j, ...............................................
,ram p
�rl����Q.�/�/ oc 'on- CCe 7C OSr ��� .�y�/G�'UG.t/ri�Q/�> It✓ i ?V/h/�.
......................_......................................... ............................ ............................................................ .....................................
Owner Address
W ....................... ............•.............---------............------•--••--•---•-----._.._.....-•--•---•---••----
Installer Address /
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_._•--•----"-----•------------------•-___._--Expansion Attic ( ) Garbage Grinder (ko)
'4 Other—Type e of Building .............. No. of ersons___.................._...___ Showers — Cafeteria
c�.l YP g -------------- P ( ) ( )
a' Other fixtures ...................................... -----
W Design Flow...............-r.�'r' _......�ooa_.gallons per p'erson�,err�day. Total ally flow..........¢��..•.....___.•....___g-Alons.
WSeptic Tank—Liquid capacit ___.__.-_•-gallons Length________________ �N>dthl______jOi__ Diameter__ -_ : ____ Depth_.S.$._._..
x Disposal Trench—No. .................... Width.................... Total Length fi'__._............ Total leaching area....................sq. ft.
Seepage Pit No--------1----------- Diameter......6---------- Depth below ........... Total leaching area.;9a.0_._..sq. ft.
Z Other Distribution box (I ) Dosing tank ( )
a Percolation Test Result 2 Performed by �'....�° _�`_..��� ? ............................. " 2 Z�'. O
Date
Test Pit No. 1................minutes per inch Depth of Test Pit......... Depth to ground water /VP*'✓E-_-__.
Test Pit No. 2_'`.....°....minutes per inch Depth of Test Pit----- ...... Depth to ground wate4_^__<(�Y!v�. .0E,�O
...........................--- =
Description of SoI_.__..._-___r -----.t------ r
�i 2 '"'l� /�'1 ��..s... C'619�5K,Sf..../� E+ ` r i .
U .........................................-••--r r 4� � r.
/-- -- tuM Gam-' dt/H SFh.✓.a
U Nature of Repairs or Alterations—Answer when applicable...........,______________________ 1,,�........._______...... ti
...................................................••----------.--._........................•.....---.............---------...._.._......_........_....-'3---._._._.........._......_......._....__.._..............................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Ti`i1..7 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 -:... --= ....••........ ----•-•...............................•----- ................................
Application Approved By......... �"- .......--.�--....... .. . =� ...............
Date
Application Disapproved for the following reasons----------------------------•---•-----------•-••-•-•••-••----......----------•--•----------•---•----•-------•---
------------------------------•------•-•-••-••••---•-•-•-••---••••----•-•-------•-------••-•-•-••---•-••-......---•--•-----------•------•----•--------••--------------------------------------•----•---
Date
PermitNo......................................................... Issued............................:.-------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............................O F........................ .
r�gltrtt#r laf (��ant�littnrr
THIS TO ER , Th fthe Individual Sewage Disposal System constructed ( ) or Repaired ( )
by . _I�stailer ..... -
has been installed in accordance with the provisions of T fZT ,State Sanitary Cca�e`as se 'e�ir} the
application for Disposal Works Construction Permit No____ ___________________:..__.____.____. da.ted_..______._-_-__-____-________-._-----_.---•.--
TAE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
DATE.......... ._'-_a{'�_.'.. .................................... Inspector... ----- --••- ...................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No............. 2. FEE.............................
Dispostt or udion prrmit
Permission 6 is re ranted--•--- .................. ......-- .......................... ...........
to Construct ) n Itidivl ew sp ✓ 00
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uw _
2V
• .. ...._ •................ .... ---- ---et-•---
as shown on the application for Disposal Worl.s Construction P1t N <. --..........................
4 ........ .................................. ---- .............•--•--•----.
r
Board of Health
DATE •. .... .........................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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