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ILCATION SEWAGE PERMIT NO.
VILLAGE
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INSTALLER'S NAME & ADDRESS/
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GUILDER OR OWNER
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DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED+
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..�...............OF......-.y✓ l.!r'►I..S.. LA (� ...
Appliratiou for Dhipuiial Works Toutitrurtivit Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
Syst at:
.. _.. L. .....f ----------------------------------- r�J ..I ti- -----------=--------------........_------
Location-Address or Lot No.
.... s..e_....Y.... ----------------------------------- --.......--------...................................
O er AdVor-
dr
....r'—_.i.....< r..� ----------------- S--ti Yc.a..� ........................................
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
a YP g ------•-•----------•------ P - ( ) — Cafeteria ( )
� 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.......................................
4
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -----------------------------------
•---------
•----------------
....----------.......------•-------------------.......-----•-----------...._..._...---_...--
0 Description of Soil...................................................•---....------------•---•--------------------------------------------•-•-••-----------------------.....•-----------
x
w
U Nature of Repairs or Alterations—Answer when applicable__.t--_______-____Ql1x_r_.1`'_1.4. ?.__. P�� F
-'-�r-.7 r�------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIE 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 b• he board of ealth.
Signed �� G% = � F.. . ...........•
�j ,D��Ee
Application Approved BY = ---------------••- f ,v`��
Date
Application Disapproved for the following reasons---------------------------------------------•-----------------•-----------_-----......-••-- -•------....._
-----------------••••-------•-•••-----••-------------•--•----------•---•.....•-•------.......------....._-----•--....__...---------------------------------...----------•-----------------••-----._...._
Date
PermitNo......................................................... Issued.......................................................
Date
✓ r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...eJ.v1................OF.......V ' ''?.. .. 1 ' ...
Applirattion for Diipuiaal Works Tnnitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
Sys at: �LCA_
. __..ti!.
Location-Address or Lot No.
--------------------
Onez Addr ss...........................................
Installer Address
Q 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
w DesignOther fixtures ----------------------------------- ----_--•---- •.•- -•-•---•-••-------.y---------------------••---------•--------....._----_�.------
er
� eptic Tank—Liquid capacity..........gallon gallons Length person e.. day. Total
d h daily flow Diameter---------------- Depth................
Ions.
W Disposal Trench—No.---_------.-- __. Width.................... Total Length.................... Total leaching area....................sq. ft.
x
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_____---___-_-_-_.-.-_-.
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•-------•--------------------------------•------•--•-----------••--•----...---...........--•-.•-----.........................................................
0 Description of Soil.......................................................................................................---------------------------------------------------•--------------
x
W -•------------------------ ------------------------••------•--- ---•-•-------------------------------------•-••-------------------------------------------------------•----•--•._......--•-•--•--•-••--
UNature of Repairs or Alterra~t-ions—Answer when applicable:_- ^------------- -..._....._iw-��
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'T1Y_ . 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is e the board *health.
Yew f �
Signed---�-/`G....
� --- ��---..�--�� '�•-•-••-�----..... --�r----�-�-�. ,
Application Approved By----- ' � /' --------------
Date
Application Disapproved for the following reasons-----------------------------•-------•------------------•------•-------------•--•--------•-----•-------........_
---------------------------------•------....-----------------------------.....------•-------------------•---------------•-------••--•-------------•---------•---------------------------------------•---
Date
PermitNo--------------------------------------------------------- Issued_.......................................................
Date.
THE COMMONWEALTH OF MASSACHUSETTS
�. BOARD OF HEALTH
............oF.. ... -'�� .. .... ./?...............................
Currtif iratr of (w,antplionrr
T ��I S IS 0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( '
G //�''1'"�
by--------- -----f---.......... --.-•-• •---••--.......... --•--...._-•----•••--------.•. --•---•...--•--•••. •----- ....-- •. ------• -_....
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at----..M t_1. _4. ..� � ,� G}2 Instal. �_ _...... ✓ .-•_•.• - ..3� tie.....
..................
has been installed in accordance1with the provisions of T 'LE ` of.The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........."............-)............... dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION ATISFACTORY.
DATE....................................... I I.S�---------------------- Inspector.............. _!1�.................------......--•--...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/0 ki� r ...........s / ....................................... F �) r
�i���a�ol � �nno#rttr�ilan rrnti�
Permission is hereby granted_.......... "' ---------•---•...........................................•---.........•......
to Construct ( ) or Rep ( ) an Indio d 1 Sewage Disposal S- 'tem-
;;7
at No.. 1 IMF f 1"C� 1 r -----------------•-..-------- __,5t ��f
Street
as shown on the application for Disposal Works Constructio it yN�o..................... Dated..........................................
DATE......................... .......................... B9 Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS