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LOCATION SEWAGE PERMIT YO.
VILLAGE
I N S T A LLER'S AM[ i ADDRESS
i
e U I L D E R OR OWNER
DATE PERMIT ISSUED R-34,) - S-'-"S
DATE COMPLIANCE ISSUED -- 'j
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F..................................._.....-..----------------......_..------..._...._.....
Appliration for Uiipoottl ork,i Tomtrnrtion Prruat
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at* .:
Jq.A. *t-e...................................... ....... .........A,....................................................
Lo lion-Ad s A h�
O er .. , �/J Addr
W ....:........ ................... kyt.... ..
Installer Address
Type of Buildings Size Lot_,�.........:....... .......Sq. feet
Dwelling i No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type e of Building No. of persons............................ Showers
a YP g --------------------•---•-•- P ( ) — Cafeteria ( )
d Design Flow............................................Other fixtures • . gallons per person per day. Total daily flow............................................gallons.
W '� -
04 Septtc Tank—Liquid capacity.�0. gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—. o. _......'°......... 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 (*0) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.-----------.................--------...
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
pr ...---..---
0 Description of Soil.. .........
x
w --•-------------------------•-----••...------------------------•---•---•••---....-------•-••----.... •---- •----- ---------- --
VNature of Repair or Alterations—Answer pheapp icable. . . .
Agreement:
The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
LApplication
provisions of TITLE 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 71�
hb rd health.
P
Signe - .......... ........•----......--------- .. ..-�® ...
Date
ApprovedBy.................................................................................................. ........................................� � �3
Date
plication Disapproved for the following reasons:.--•----------------•-•--------•------------•---•-------------•---------------....------ •-----------•-•
-----------------•---------...........--------•------------•--------....-------•--•----........--------------------------------•---------------------------------•-..---•---•••-----•-----•-•------
Date
Permit No.... = ...............•-•--•-.. Issued...��--. 3,9 Y...............................................
- - Date -- ---—-------------------
No................w'.. .rJ FEs....... "..... --
�a�....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................O F...........................................
. VVftrativai for DiupwiFal Workii Tnmunrtinn rnrj;
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage=`Disposal
System at- "
�" Or
L>a Add re
- ------ --------- ----- --...................---•-- ••.•-----••-------- .......A- :_�/Z...�,....---------...----
... ...____-_
Installer Address
U Type of Building/ Size Lot�'3..........�........Sq. feet
.� Dwelling 6�No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures --------------------------------------------------------•---------------------....-----------------------••......---
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
0: Septic Tank—Liquid capacity.14?gPgallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
Depth below inlet__..__........._._.. Total leaching area...._______.......sq. ft
Seepage Pit No.../._.___._,_.____.. Diameter...................:
Z Other Distribution box (1-1 Dosing.tank ( )
Percolation Test Results Performed by..-..---------------------------------------------------------------------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ----•------- ---------------------•----•'••--•••--------------•-••--------......-------•--------•-----•'•••--•----••----'•-••-•----•--•---------------._----
0 Description of Soil------............. •---•-••...............•--••--•.....--•-----------------••----------•---•----- •----------•-----------.......-•----------•-•-•-------...........__.
x
W --------------------------------------------=----------- -------- t
U Nature Re air or Alterations—Answer whe ap 'cable --�G4►t ,
----------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE; 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 hrd health.
� /�-~�� '" a - 3
Signec> -------- ------•--................................................................
A lication A roved B W1 - 3 Dale p.3
PPPP Y ........................................
Date
Application Disapproved for the following reasons-.................................................................................................................
Permit No..... .... Issued._ _��...••.�... ---... ... .Date......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..O F.................I
f° (9rdifiraft of fl amplittnrr
THIS IS TO ACERTIFY; That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by........ '--- /', /=.ri wed' �• G ",,
•........................•-----'-......--'--•--••-----------•-----:_....-------------------------•--_____---•--'--=_........-----•---•••----.....-•-'-'---'•----•-------
Installer
at.....................u................................................................................-----•--------.....-----.._..----------......._........._
has been installed in accordance;w th-.the provisions of TITLE • 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permlt'No.,........................................ dated......�`_.:�'.�-=- ...3...........
•--...--
THE ISSIIA CE F THIS CERTIFICATE SHALL NOT BE CONST AS A GUARANTEE THAT THE
SYSTEM WILL U zTION SATISFACTORY.
DATE.... Y.. T...........::.................'•"-•--"-'-..---- Inspector.-- -- --- ............................................
a
THE COMMONWEALTH OF WASSACHUSETTS
BOAR��OF HEALTH
�Cce��. efs�sr=S>7...G�� t'u
^ aC/ -::..OF......... ... FEE fC.
- �i �r ttl Turku 'Wunu#rurtiun remit `
Permission is hereby granted.=f ----•.................•--•--.._.....----•---•-------••----...•----------------------........----....................._'--'..
to Construct ( ) or Repair ( A) an Individual Sewa Disposal Sy t US` re# 4_11e e .
ga Dis- L `=
Street 2rj `+ ® rr
as shown on the application for Dtsposal Works Construction Permlt No_____________________ Dated____...__'��/_.�r✓..........
A b /V x. ................
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�IIoard of Health
lJ h
DATE ! ... ...:...
FORM 1255 A ,MK,Y SULK IN, INC �BOSTON -
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