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KEEPING YOU ORGANIZED
No. 10334
2-153L
MADE IN USA
GET ORGANIZED AT ShAEAD.COM
LOCATION SEWAGE PERMIT p0•
SZ1 za S
VILLAGE '
A = i /+ i iz(a
IHSTA LLER'S WADE L ADDRESS
0UILDER OR OM3ER
N Al v A A)SC Al .
DATE PERMIT ISSUED >
9/Z
DATE COMPLIANCE ISSUED
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QtN
FRic
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
j
...............QLt,n.......0 L .),?,2�5. ..1 . •....................
Appliration for Uhspnsa1 Workii Cfutuitrurtiumi- rrutit
e_
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
...... . - .........
-ddress No.
Y ...... ....... Lot
.......... - -•-•• YArt....................................................
Owner Address
- --------------------------------------------------
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms.................................. .Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................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-_-_-______--__-__-____.
------------ .................................
O �j Description of Soil---=---•------..._.. - - L�- --T ��..........................................................................................
V -----------------------------------
._....-----------
•--------------
----------------
--........
------•-------------------------------•----•--•-------
W ••--------------••-•----------...........---.........------------......---•-•------------..........._...--••-.... -----------------------.)....----•-----------••......-••-•••••---.•----
UNature of Repairs or Alterations—Answer when applicable. !__-•-/cvL,'............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'LIVE: 5 of the.State Sanitary Code— The undersigned further agr es not to place the system in
operation until a Certificate of Compliance has bee issued by the bo of health.
Signed--- =,1- - ------ - ----- ---------- D•• --..
Application Approved By ................................... f � ......--------
Date
Application Disapproved for the following reasons------------- -------.-----•---•-----------•-----------------------------------------------------•......•••......_
....................•---......---•-------------------•------......-----.....----------.......•••••-•-•---_....__.....••••-•--••-•--•---••••-•-•-••-••--••-----••••----•••-----••--•--•----••-..........
Date
PermitNo.......:................................................ Issued.......................................................
Date
�r
Fps* < ,� d:.
THE COMMONWEALTH OF MASSACHUSETTS
�. BOARD „®F HEALTH
.. O F _. . .....
Appliration for Bi_qvnsal Works Towitrttrtion .eritti#
Application is hereby made for a Permit to Construct ( ) or Repair ( -r°an Individual Sewage Disposal
System at: �* l
.... r ... .......... ..............
" iodation Address € ti• riLot No.
... .....,,,.1
W , •� , r O a} r .... .............
J x y ! 'Address
,� /.P.w` flf Yv!'7 jA' Pf �/ ..� 1,�............._t__�_yP?_L/ T 1.J'l�.tywr_._._...
............................. ___•____ ...M........... __ ..__.�. ...-..... ...._..................................
Installer Address
dType of Building Size Lot................... q.._....__.S feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
persons............................ Showers — Cafeteria
p`4„I Other—Type of Building ............................ No. of p ( ) ( )
Q' Other fixtures .----••............•=......----• ...._. .
.W 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 ( )
'-� Percolation Test Results Performed by.......................................................................... Date..........................................
Test Pit No., 1.........:......minutes per inch Depth of Test Pit---------I..._....... Depth to ground water_-_-_______-_-__-_--.---
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
. x - .
O Description of Soil----------------•-" p--/ t` � -..
x ------------------------------------------------------------------------------ .
U ......••----•----------•-••••-••-••-••------••-••---••--•-•----...•-•-•---=;..-•--.......---•-•---------------------------------------------------------•-------••---------------------- ---------
W -------------------------•----------------------------------------------------------------------------------- --•---------------...--••-------------•------•-•----••----------••--•---------•---•.-•-•-
U . Nature of Repairs or Alterations—Answer when applicable---------v _ s_!----�-------- ..................................
••-------•-------------------- ------------•-------•----------------L------•--------•--••-------•-------•-----------•------------ .....................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance'with
the provisions of TITLli 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/b�4 of health.
� /Zi
a � Date
Application Approved By....._,._..1�� = 'F � -••----------------------------- ! Z'�; � .......
Date
Application Disapproved for the following reasons:---•-•••-•••----••••••-•-•-•--••----•-----•-•••--•••••••••••-•--•------•••------•--------------------••--------
--•-••.......................•-•---•-•••.....••••----•••---••-•--••--......••--•••------•--•----•'-••••-•-•••••••-•--•-••••--•••••-------•---•-•-•---------------•-----••----------•••......--..._..._.
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
,_ ,�,^� • BOARD OF HEALTH
� � r.,;s>�.........OF.......,°,...`::..... .:!.. `"
�... ...............
Trtifiratr of Toutpliattrr
THIS.-IS TO CERTIFY,
That the�/Individual Sewage Disposal System constructed ( ) or Repaired
.....................................
by = ! r t .Installer ---------
at. t l `ol� t ^' �_�.... :?
...__._�.:. ............. ............................................`.__.__._..,_ .h.__._. ..C_._..__ ._.___.___.._._________.___................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.....3 1."_5.i__:-_-___--•_. dated-.--------............._....._.._....._........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......---•-•--.....--•.................. \-L�_1.?� Inspector............................... ..........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
fb6
f r�if! !,2?.. ...........O F... fdJa4`<!:� �.i C +E fl,.�•',C�' ..... �
....... .......................
No...�....�. `....:3.�. FEE. .:: ........
Permission is hereby granted-----.,. ._.y�.�t' `�` -'•-_'............... .'. — ,
to Construct ( �;br,Rep i (1 ) an Jndividual Sewage Disposal System e
F ,� , I r
F Street
as shown on the applicaiion for Disposal Works Construction Permit No..................... Dated..........................................
oard of Health
DATE........................•-----------------------.............................•-•
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS