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No. 103't.l.
2-153L
MADE IN IJ$A
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEP TH
.......OF......��.a .. f.. .....d ..... ---------
Appliration for Biipnsal Wo",S--
mitru.rtinn amit
Permit Construct e air an Individual Sewa Application is hereby made for a Pe t to Co st ct ( p ( ) Sewage Disposal
�System : `` �0 /
. -•-•- ........... ------------------------------------•-••••--- ._.._..... -------------------
Add
/�. ..... rr�/i� .... ...........$'SS`
n 3
W O ���1�� 4'�res-� ...
.!/ _.._........ ._..
Installer Address
Type of Building' Size Lot---
_6j_.__._ _ ...Sq. feet
,. Dwelling—No. of Bedrooms....... --------------------------------Expansion Attic ( ) Garbage Grinder ( )
pa., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
aOther fi tures ...... ...................................................................................... ------------
W Design Flow.._....�_9..............................gallons per person per day. Total daily flow_.__.__...!?r_ __v_.____._.__._____..gallons.
4A. allons Length Width____._--_.____-- Diameter_---_.-______._- Depth_-_-_____------.
W Septic Tank—Liquid capacity_ g
x Disposal Trench— __ _____ _________ Total Le th__ ._._._.__....._ Total leaching area......_.____..__..__sq. ft.Seepage Pit No....S�.6 Zidth
.... ........ ................. Total leaching area.�.0,_......sc.4,9�
Z Other Distribution box ( Dosing tank ( ) �f"�7
Percolation Test Results Performed by a--?. °^.-,-••....................................... Date___« �.� j.....
Test Pit No. 1................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........................
t� ..................................................----------- -----
...
Description of Soil. C>.". _ > l� =•�I�^ •----------------------•-------•--•--
....... .*,
�.,
W -------------- --------------------------------------•--------------------------------------------------•-------------------------------------•----------------•-------------------------...__.....----
VNature 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 iITLL 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---•................................•----------•-----------------------_._._.._--•--- -----------------------•---
Date
Application Approved By----- ------------------------------------------
Date
Date
Application Disapproved for the following reason ------------------------•-------------------------------•-----------------------------------------•-......__...._
............................•--------••--••--•---...-----•......-•---•-------•---.....••---••----------••--•...------------------------------------------------•--------•-----------------------------•-
/ ,�p�
Permit No......................................................... Issued- -�` ..... •---Date
Date
L � _
sl 7►
No.....U._:.:fU Z ................_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
-.. ... OF...... -'."��. } .��. 42
..__........:4 .....................
Appliration for Uispas ai Mork,- Tonstrnrtion rrnti#
Application is hereby made for a Permit to Construct ( )�or Repair ( ) an Individual Sewage Disposal
System at: ,,
F Loca", .
Addre — ~
or Lot R'o
'— = ........... ..........:� ... i _... .
Ownena �..
�
dress9
� Installer Address
Type of Building Size Lot.. feet
feet
Dwelling—No. of Bedrooms-------:_________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers
d W � — Cafeteria
Other fixtures ----•• ---------------------------------------------------------.--------------------- ---•; ----.-----••-•---••-•----•_---(_-••--•)-Dsg �0 gallons per person per day. Total flow ....................
gallons.
(� Septic Tank—Liquid ca acit .� •� �
W � ons Length •-- Width _-• Diameter._r___.._-----• Depth................
Disposal Trench _� ____. idth Total Le t_ ______________ Total leaching area....................sq. ft.
x ,�
See e Pit No Drarne£er' -De tl below`nl'et�................. Total leaching area.��4�Z�._.___s ft-
3 P k ---&j'! ,P P '.r g q- .
Z Other Distribution box ( �) Dosing tank (
Percolation Test Results Performed by....... '------- � Date....Z(2._ !7/7l
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........................
x
ODescription of Soil.......r-.,-3 ---- ...................................................'3 '- i(. =� ._. ---- "'�.......� :.�--:-------•..._..---•--•.............
x
w
U 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 T IT!L- 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.................�_..-------------------•-•-•------------......--•----•----.._.....-- ....--•••--•naYe_..--•......._
Application Approved BY............................ ----•-'%/j-•%/ ,-f------------•--.._...---•-------------- ---`---=`.....---.--1----•---'-------
�/ / Date
Application Disapproved for the following reasons___ ___________________________________________-----•------•-•••••••--•••---••-••••-•---_ ---••••__.__.
---.......................................................................................................................------•--------•-----•-•----------------------•-----•--••-•••--•-•--••-----_.
Date
PermitNo.......................................................- Issued_.......................................................
Date
a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
u
.41 ..... ;.......O F.. \54..�".w ,' tt31 ............................
(Irr#ifirab of (lam' -pliFanrr
THIS IS TO CERT, Y, That the Individual Sewage Disposal System constructed ( or Repaired ( )
bY---------.�-....r- - r,------�` �'�- ��----------------------
/�.
at. r"t= ............................ __ R��l.: __..-•„t�w Installer ----------•---•-------------------------•------------
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......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....... 1.��......li� ............................................
Inspector..---- - �
.7--------------
THE COMMONWEALTH OF MASSACHUSETTS
BOAR I
OF H
.............. .. ...OF..... . _ ..........................
No......................... FEE........................
Dispos IV kil ernti�
Permissionis e y granted....... ---••• ....... ... ........ - -i.. .. ..............................................
to Construct Repair ( I iv Sewage Dis em
atNo........ G(� �-•--•---•. -- �- ......................
Street
as sho on the application for Disposal Works Construction Permit No..................... Dated__, _"-_�`�...__.__._....
...............•--------•-----------------------------------------._...---•-•---••••-
�'�a...............................................
Board of Health
DATES 6'
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
4,;e- 46 _ rap /off
LO CAT M i SEWAGE PEQVIT p0:
VILLAGE
USTF✓�Y«C�' /�J�Q
IBISTA LLER'S NAME & ADDRESS
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58 T 4.4P4es C, i� WFs'T Y•4,P�i a�! / 9
0 U I L D E R OR OWNER
C?o cc,e,¢S C-o
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DA T E P ERMIT 1SSU E D 2- .2
DATE COMPLIANCE ISSUED _
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