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THE COMMONWEALTH OF MASSACHUSETTS
ASSESSORS MAP N0:
BOARD F HE T I Z 2
PARCEL NO:
' .........OF... ... ........ ............................................
Appliration -for Bi-qVuiitt1 Works Cnonstrurtiott Vrrmft ,
Application is hereby`made for a Permit to ConstructL'®rair ( ) an Individual Sewage Disposal
System t 01 ,10e
�� a� �
C Locat• -Address or Lot No.
/
W w e� . wss /tf
Y
Installer Address _
Type of Building Size Lot.... feet
Dwelling—No. of Bedrooms..... ...........•___-_---_--_•----_--__.Expansion Attic ( ) Garbage Grinder ( )
A4 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ......................................................
W Design Flow......... .........................gallons per person per day. Total daily flow......... 3:2�...q.................
Width---------------- Diameter------- 1.....--- Depth W Septic T«nk—Liquid capaci ............gallons Length...............
x Disposal Trench—No. .................... NNE. -------------------- -F04-L ength._............_ _. T 1 leaching area---------------------sq.4t.
Seepage Pit leaching area.� e-7 5�_sc ft.
Z Other Distribution box ( )/ Dosing tank ( ) p 6 /0-/ ?- 76 /°4
aPercolation Test Results Performed by----------------------------------------------------------- __ Date---------------------------------------.
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
4q Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water_-._-.._-_-_--__---_-
P4 ........... ------- - -- ----------------•- ----------
Description of Soil_- " :.
vx �P' ie ....1d1- ------=-----------------------------------------------------
---------------
------------------------- ----------------------------------------------------- -------------------------------------------------------------------------------------------- --------------------------
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 Article \I of the State Sanitary Code—The undersigned further agrees not t?,Place the system in
operation until a Certificate of Compliance has been issued by the boar of healthy� 11:
/ f
i � � i .
g G
•��. Date
Application Approved By--------- ---- - -- •--• ................................. --------7-7-------
Date
Application Disapproved for the following reasons-----------------------------•------------------------ ---.=-•••• ------ -----------------------------
,' �;.
-----------------------------------------------=------------------------------------------
i yP.• i Date
_
Permit No. Issued. -----------------.`............------... .
Date
No.-- ....... ..,� Fl�s.....` ..............
THE COMMONWEALTH OF MASSACHUSETTS
— BOARD OF HE LT
... .........
Apphrtttion -fear Diquniitt1 Workii Tottstrurtittn Vrrufit
OApplication is hereby'made for a Permit to Construct4(- J o R air ( ) an Individual Sewage Disposal
System -
/.� - - ___
Locat' Address or Lot No.
_ -'
w er/ / Address
. � �. -••--••---- --•-•------------------- ------•r% rtL''t• �.� .
Installer Address _
<11 Type of Building Size Lot__-% :_G q, feet
U Dwelling No. of Bedrooms._-_-_ ..----------------------------------Expansion Attic Garbage Grinder
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures --------------- ----------------------------------------------------------------------------------------------------------------------------•-------
W
Design Flow......... ' ........................gallons per person per day. Total daily —3 flow----------- ....._.._..........gallons.
USeptic Tank—Liquid capacity" Mons Length--------- Width---------------- Diameter_______________ Depth.._..._-_..._..
xDisposal Trench—No. .................... NV p4h______--_____-_ .... Tot�'1-Length------------_____.. To�1 leaching area-------------._-___sq. ft.
Seepage Pit No ��::.:."�DI 9e D 7ft e3t��� efi-------------------- i leaching area-__r.o. .sq. 1t.
z Other Distribution box ( ) Dosing tank ( ) o,�j. ��./q.. 76
~" Percolation Test Results Performed by_________________________________________________________________________ Date-------__-.-.._.-_.------.-_--._-------.
W
Test Pit No. 1--------------__minutes per inch Depth of Test Pit.--:-_--__--__.____- Depth to ground water...-__----------
w Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground.water--.---_--_._____------
- -••---------------•--._- .
O _..-• `
i.__. i
--------
Description of Soil---..•. !�1'�t �� o-v �!`+' *� li =�.. ..-._----
LQ_=_C° su-•
U ------------- ��I�J.
- ---- �_ � �'�► ......
UW -------------------------------------------------------------------------------------------------------------------------------------------------------- ------ ;-------_----------------
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 Article XI 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 boar of health.
F 9 /
Date----••-------
Application Approved By----- g-• Yb / `
Date
Application Disapproved for the following reasons------------------- -----------------------------------------------------------------------•-____-------------_-
-----------------•-•--•------------•------------------------•---•---------------------------------------••-----•-••-------------------------------------•-----------------•-------------------------•-
Date
Permit No.......................................................... Issued---------------------------............................
.
I Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH, �o
t,
......... .........:
�rrtif irtttr of f'llntphattrr THIS TO CERTIFY Tim t�the� ividual Sewage Disposal System constructed ) or Repaired ( )
by........ -F' ............ � °� '.-�'- ---------- r'_ -
fInstaller y���
jam;=` ---•-' •---.-.r:" .!(. i_�-•----•-'"•-- __ _.__s�...7✓ --•--- .... �' ,,�----------- .. _.__ =^G_'�i.e'!C.,,rr---••_--•---
has been installed in accordance with the provision ooff Art XI of Tki'trState Sanitary Code as described in the
application for Disposal Works Construction Permit No.-- ....t/0-_d_A----------- dated'__.1_4.!!!.*7.-'e...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION
SATISFACTORY.
DATE..........
(.......... ----------•-- Inspector---...- " -------
THE COMMONWEALTH OF MASSACHU TS
- BOARD F HEALTH
.�
NO.. �Gf_v'---- FEE
�i��n�tt nrk,� �ntc��tire" tt �rrmi#
Permission is her bunted. r „'�`G f.-:ham--! ?_r ?
y
to Construct ( 1) or Repair ) a ridividual Sewage Disposal Sysi�tQn
at No. •-Y
��• � `- � Street ,,,,.-,i� '
as shown on the application for Disposal Works Construction P mit .----__ �_-- Dated....3"�'._...�'__7______________
y�,DATE .... g --_7 7 Board o ealth
--•------••-•----------•--•-•-•--------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �'"
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