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LOCATION SEWAGE PERMIT 910• .
80
VILLAGE
I N S T ER'S NA23E a ADDRESS
QY
8UtLDEIt OR OWNER
DATE PfN III IT ISSUED
DATE C0MPLIANC.E ISSUED ,:2AzIS2
i
e.
_ 31 �.
PON60 D
ib tt
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THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I -A-
DATA
3 THE COMMONWEALTH OF MASSACHUSETTS ,._.
BOARD OF HEALTH
.. ... ': f...........OF..:_� �. j � ..
Appliratiou for Dippoti ai Workri Tnnitrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at: -•,� ;
}
• a, ;f,3 .: .. �..... '±�....:............. .• ...... ..... .•... ...
. j ) t:L'.ot l N.oLocation-Address .l:..J
........ -. . .. .......................... ......... .....................
.. .." } . ,.,w.!. .........................
Owner Address
W Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( Garbage Grinder ( )
Other—T e of Building ............. No. of ersons.........._.._......._____ Showers
a YP g --------------- P -- ( ) — Cafeteria ( )
Otherfixtures ------------------------- ...................................-.........................................................................................
W Design 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........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit............_....... Depth to ground water........................
G% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x --------------------------=---------------------------=------------------------------------------- ...............
Description of Soil.......................
V ----------•------------------------•-------------.. -----------•---------------... ---------....__....: ----------.-.--..........................................
�l ...•-------•-------------------•-----•----------•---------•-----•--••---•-------•---••-----------------•--•••--- -- ---------------...............
U Nature of Repairs or Alterations—Answer when applicable.......... ". 47
?{;
r -
--------•------------------------------•--•------------------ •--._.....-------•-----------•--------...---------------------------------------_:___._.._.......---••--••----•.....-•---•---.....---•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T '12 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.,,
Signed...., ....: t;...........
-
1 Date
Application Approved B
Date
Application Disapproved for the following reasons-----------------------------------•--------•-•-------••-----•------------------•------•---•----••-••-----••----
------...---••...........••----------•....................•----•---••••-•-•---•-------.........-•--•---...-•-----------•----••-••----••---•-••-----•--••--•--------------••-----•----•••••••----.........
Date
PermitNo......................................................... Issued-.................................. --•---•---•---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
fCf.............`...................OF........... �....... .....
%un ifirFatr of Tompliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (,M_)
by .f r '.. . s; > .I.. ---- --•- -----•-•----•------------------••.......----- --.. ..-•---
�P '
.............
Installerat
# rr }}
........'..._....__.. .__..,............................. ......... 'O•
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.__ : _►_7• `l............. dated-----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---•...........................•-•------------------•�1;V--- Inspector...-•-- ��.-404.14l
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�,d ( •� {A1
,
..:.fr ,k ., �............OF.. t .
, a' a� �' >�� . {
No `'�.:. �. FEE-....................
Permission is hereby granted..... ' ..... _ *_. .�'t ' 'r 'r r it
to Construct ( �) or, Repair ( ' ) an Individual Sewage Disposal System
at No.•-••••• .... , .. t
i Street
as shown on the application for Disposal Works.-Construction Permit No..................... Dated..........................................
for
of Health ~
DATE............... � 1 '........... ...............
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS