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THE COMMONWEALTH OF MASSACHUSETTS
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BOAR® OF HEALTH
'/...�i�G OF..............+..- . 'Z' �1'1.=--------------•-----------..._..............._.
ApplirFa#ion for Dhiposatilorks Toutitrnrtion Permit
Application is hereby made for a-Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: r
_`' I�-�'�_---- ?..r`�...........E_��......d�'ft t��e��....................................................... ....---------------
/ / Location Address I or Lot No.
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:... ... � .j
. ................................................*7..... ...•y ...r ............ --....------..............................O
Address
Installer Address :ry
Type of Building/ Size Lot_..........._! Sq. feet
Dwelling—No. of Bedrooms......s?.................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ................................. .
Design Flow- _'----- --------------PWgallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width...............:... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------- .......... Diameter./ _.`�epth below inlet.................... Total leaching area...% ..sq. ft.
Z Other Distribution box (1_) Dosing tank 7" 7 lz-
�" Percolation Test Results Performed bY-----------------••------------------------------
-...................... Date........................................
`�./..__
Test Pit No. I....... __minutes per inch Depth of Test Pit.................... Depth to ground water........................
L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
w' •----------------- ---._._...........`.......................................•--•- ..--• .................................
_ i
Description of Soil......... ................�'t ------s-•--V � •--1� . P�'`.._���_sc�s_LC-•-----------------------------------
U .......................•------------•--•--•----•-•---------•---•-----------•----•------•.....•--•••......-•--•---••-•---....----••------•--------•••-•--•-•-••--••------•-••----•---•-----•-•-•---•-....
--------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------..............
0 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 iITiZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss ed by the board o health.
Si
gned=- -.......
Date
Application Approved BY �. (�` /f� ,%i��!j = ------------------ Date
Date
Application Disapproved for the following reasons:--•-...-•-----------------------•---•-----------•-•--------------------------------------•-•--••-----•-----•---
-•.................•-•-••-•....•-•••----•---•-•--•--•-•-----...--•--.....---•-•----•-...............__....----------•------••-•--..._------•----•--•-----•-------•--------•-••-•--••------•---•---•--•---
L
Date
PermitNo......................................................... Issued........ ..................................
Date
No ........_ FEs !!! ..
�^ THE COMMONWEALTH OF MASSACHUSETTS
BOARD ® HEALTH
.......... ..........OF.............: . :. +++!f!" ..............................................
f Appliration for Uiipnsal Workii Tonotrurtinn ramit
Application is hereby made for,,a Permit to Construct-( ) or Repair ( ) an Individual Sewage Disposal
System at
/pj}
... ocat n.': are ,7
or Lot No. ........_
._.
~ Ow Address
.7-------- -------------------------
----------------
........
...---------------------
------------
Instal ter Address +�
Type of.Buildi Size Lot__ ' ........Sq. feet
V 11
Dwelling—No. of Bedrooms._____ ______________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures ..
------------------------------------------ ----------- ---- ...................VP
........
Design Flow„___ _____ - gallons per person per day. Total daily flow..__._ �► • _� ................gallons.
WSeptic Tank I Liquid capacity !ga]lons Length................ Width__. . Diameter_____.................. Depth................
x Disposal Trench—N ..................... Wid h �,� Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.______._ --_ Diameter .. ...Depth 'below irjlet.................... Total eaching area___aV..sq. ft.
Z Other Distribution box ( Dosing tank ( ) �*► 0 ''' Az " "' ►
Percolation Test Results Performed by.......................................................................... Date----- ..................................
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 ..............
Df +>r» 5 ...........
a' Description of Soil..........: A* 'f �" +r [
W =----•---------- - ---
..-••••••••••------•......-•-------•---- --------------•---- -----------•-••••----•--------•-
U Nature of Repairs lor Alterations—Answer when applicable_.___:.__ ._._.__ :.__:____ :___._-_: _______________:________________________-_.
- ----
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee i ed by the-board o health.
«,
Sign e -• :•-•-••- •--
Da
Application Approved BY ''. ..................
Date
Application Disapproved for the following reasons____________________________
••--•-•--•-••----•-•--•--•-•-•-•-•••----....••--•...------•---•-------•-•------••-•-•--........•••-----------•---•-•-•••-----•---•••------••----•-•-••--••-----•--•-------•-•-••----------•••---...-----
Date
Permit No..................::::..•---•--•----------••----...:_._. Issued............................
............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
1 ...O F...... .. ... ..-.....: . :;
R
(9rdifiratr of Tnntpliatta
T IS CERTIF That the Individual Sewage Disposal System constru tea ( " or epaired ( ).
b > " -•
...........
....
4
�ystauer
has been installed in accordance .with the provisions of r f.The State Sanitary Code,`s des ibed in the
T application for Disposal Works;Construction Permit N ,__ _. _............. dated-----�'`�_ -- _______________
THE`ISSUANCE OF THIS CERTIFICATE SHALL NOT BE E CON RUED AS A GMARANPE THAT THE
SYSTE, WILL U CTION�TISFACTORY.
•--••--77•. ...............•--..._........_.. Inspector.......-- -•- ------•-----------------...........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O)j HEALTH
Aor
No::::...:..... :. FEE---...&.........
Dipvollztl kil #rltr inn rrrnti
Permisslo_, I ereby granted _:t --'-- .444 ' r: • - .. :.
to Constru or Ra air ( an In v ual evv Dispos ystem
at No...
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t � Street �»�►
as shown on-the application for Disposal Works Construction P it No _:__ Dated.__`,�t _ .J5P'�. __:-- �
F. Board of Healt
DATE.."'-., .:_:..•_ -••_.. ... -
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
LOCATION SEWAGE P RMIT NO.
VILLAGE
d ST-EGZ V I L C,
I N S T A LLER'S NAME & ADDRESS
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BUILDER . OR OWNER
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DA T E P.ERMIT ISSUED z9
DATE COMPLIANCE ISSUED 9-I'-?T
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