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LOCATION SEWAGE PERMIT NO.
VILLAGE /
INST 'A LLER'S NAME i ADDRESS
® U I L 0 E R OR OWNER
DA T E P ERMIT I S S U E D 7 �l � z
DATE COMPLIANCE ISSUED 7 /
of au i
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
70110j).........OF....... lr 1. --1._ .....................
AVIVIlrFatiou for Bhgpvii al Work,5 Tnmun.rtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( i Individual Sewage Disposal
Syste��at: ...6 '� ... ...
r a�........ ............ .._........
s - or No.
_ � .......................... .............
�l .. 11�.1 ......--
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O ner A dress.
a •-• . .cn.. Y :.1.-1 ---------------•-------------------
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ................................. .
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--__-____.___---•--_.__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil--------- ` - -- -- - - - ...............
W ••••••----------------------•------•---•-•------._...-••-------•---•-•--•---------•----•-•••--••••••-•----•--.....----- - - ------------------------------....••-•.................................
Nature of Repairs or Alterations—Answer when applicable-------------- -_J_Q_(,1.�...�-al----___ ---- f-----___--...........__.
--------•----------------------------------•----•----------•------------------------.............---•-•---••--••---•-•----------••-•••-•--••--•••••-••••-•---•---•••--•••-••-•-•-••-•••••-••-.........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beeg issued by the boa ,,jf health.
Signed_._.. • � ,� ���� .....L.7j-9�-----•-
Date
ApplicationApproved By...............................- -----------------------------------------------------•--------- .................. ........
Date
Application Disapproved for the following reasons:......................................--------------------•----...........----•-......---•. ._ ........._
--------------•--•--•------••--------......--------------.........---•--•-----•-•-------...---•---•:......--•-•---------------------------------••••.
Permit•No.......................................................... T
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
IM ^�c� C
DATA
Fizz
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f i 1..1.........OF...........�. � %, J�•�-1' .�.
- . .......................
.....................
, pphration for Uiipuoal Works Towitrur#ion ami#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: — 1
.. . ,i r -,r........................�i I
Location-Address` _ or Lot No.
.........s- / )
---•------.(. .................t.... ..........................................Fr---------..._...-t----------------.:...................--
1 �W e) l� I f ( : / 1.1 }A�dr�ssl
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures -------------------------------- -
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........................
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.....................Depth to ground water........................
a' •-----------------------------------------------•-••----............-----•------•---••-•-•-••-------.........................................................
0 Description of Soil....................f L ! ! / / /� ` r /
x
W --------••------ -------------•••-••--•----•••----------•---------------•--------------...•-•--•--------•--------•------..----------•--•---------------------------•-•----....--•--•••••--.....--••-----
U Nature of Repairs or Alterations—Answer when applicable................/...........r.........-................. if
----•-•-•-----•------------••--••---•-......--••-•-•----•-•-------------------------••..._.......-•--•-•----------•--•--•------•----------------•---•••••----•••------------•--.._............_--•_.----
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Tl=- 5 of the State Sanitary Code— The undersigned further agrees not'to place the system in
operation until a Certificate of Compliance has beent issued by the board,of health.
�z-. ,
Signed..... : .......... ...........................
i ��' Date'
ApplicationApproved BY - ------------------------•--•-----------•--..........•-••-- `f ------- --- ----------...............
Date
Application Disapproved for the following reasons:..............................................................................................................
............................••---...---------------------•--...--•---.......------------•--•--...........•-----•----•---•--------•-•---•---------------•----------------------------••-•----•...........
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.................................. ..........................
Trrtifiratr of Tootpliana
THIS IS TO CERTIFY, That the Individual Sewage-Disposal System constructed ( ),or Repaired
by.................................
/ r r Installer I
— ( , I 1 1. . -T_ /� /) IiC /' If
at•------------------------•------•`•....-••-_............................................................- ----------------------------------•-•-----._....... --- -----.......-------•----.
has been installed in accordance with the provisions of TI r 5 of Tl tate Sanitary ode s des n the
application for Disposal Works Construction Permit No..... � -............... --,--. da.ted.......... ..... .. .... -------..-
THE ISSU INC OF THIS CERTIFICATE SHALL NOT BE CONSTRU D - A GUARANTEE THAT THE
SYSTEM WIL F TION SATISFACTORY.
f` DATE.....
2.�� . ...................................................... Inspector.......... ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No..... �... FEE........:...............
Disposal Workii TDono#rudion antic
Permission is hereby granted...................... . ' I ! '
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
1
at No......'...........................................
.........._....:.._...... ._... ........ ------
Streetr
as shown on the rapp ' do or Disposal Works Construction Permit No.._....•:__:.r�"" a 1'- .......... ...........
'j•Bo of HealthDATE.-----2 ---- ............................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS