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LOCATION dZj EWAGE PERMIT 930•
NTH A G
INSTALLER'S NAME & ADDRESS
6UILOE0 /jOR DON ER
113 r
DItTE PERMIT ISSUED -$ +2�c�- _
DATE COMPLIANCE ISSUED
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06 75 6 33
FE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
1.... .-Yl.............0 F........ CC-f I7 cS....... '__.i..............
Appliration for Disposal Workg Tongtrn.rtiun rnmit
Application is hereby made for a Permit to Construct �Y) or Repair ( ) an Individual Sewage Disposal
System a • •- _ d
l/�lJ
.................. ..` A... h4........... t ........ t Lot No.
om. s.........-.........
cv n-Address (� �-t h
or
�Ins;a
r ... dress ........................_.....
a c�. ... .. ra... _..., .. ._...._ . . . e lv..---------------------------••--
ler Address
UType of Building Size Lot_.Z 1. .......Sq. feet
�-, Dwelling—No. of Bedrooms............&�---------------_-----_.Expansion Attic (�� Garbage Grinder WO
aOther—T e of Building g ............................ No. of persons...... ................ Showers (y) — Cafeteria ( )
Other fiur�s
W Design Flow..............._.�•�......................gallons per person Der 0y. Total daily flow....... .. ----.............._.. lons.
---•--
Y .
WSeptic Tank—Liquid capacity/d0 Qgallons Length- ,,s-.... Width---6.__._.._.. Diameter................ Depth...
x Disposal Trench—No............................. Width._..f.............. Total Length..._............__.Total leaching area....................sq. ft.
i Seepage Pit No......./........... Diameter.-..St
iameter:.. ............ Depth below inlet................ Total leaching area....1U..sq. ft.
Z Other Distribution box V ) Dosing to )
'-' Percolation Test Results Performed b __... __.. �Y Ya ti°_itr. eS '
,a Y --- �---------/.:.�:-•--------------- Date----- �TT�-y.'_��.__..��
Test Pit No. 1.... ..---minutes per inch Depth of Test Pit.....6..�....... Depth to ground water..I_Y__O. b,
f�. Test Pit No. 2................minu-tes per inch Depth of Test Pit.................... Depth to ground water.........................
Rai -
O Description of Soil...................
----...------....----------•-----------------------....-----........---------...-------------------------•--•....---•--
x
c.,
UNature 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 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 i su by the bo,arl of alth.
��� �
Signe .. ....... . ....
Dat
Application Approved BY Y! ----/.l .. Z de
obt. IV !>�,
Application Disapproved for the following reasons:............................................... .... ..
.........................•---•------......._•-----------•-
Date
PermitNo......................................................... Issued.......................................................
Date
No. ..-. .v...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
.... OF........�/.a-r= �es.......�...d l�
Applira#ion for Disposal Vorkg Tnnitrudinn Frrutit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System : 1
........ ....... •--- .......----- ----------
Location ......... ..............
•Address r/ V �e/�w 1"0 s
W .Address
a ..................... ^^ .. .............
Installer Address
dType of Building ?? Size Lot__ --� --.G-------Sq.NO
V Dwelling—No. of Bedrooms............LJ.__---------------------Expansion Attic (Np Garbage Grinder
04 Other—Type of Building
p� yp g ____________________________ No. of persons............................ Showers .( ) — Cafeteria ( )
QI Other fi ur
--------------------•-----•-----------•-----------•---------------- - t�
W Design Flow._..___.... .................gallons per person yer ctay. Total daily flow....... ____1--- ............._._lyJlpns.
WSeptic Tank—Liquid ca acit /000 gallons Len th_ !f.__. Width..k.......... Diameter................ Depth--- .........
x Disposal Trench—No..................... Width...............:... Total Length..............r.... Total leaching area....................sq. ft.
........... Depth below inlet.._. ....._..... Total leaching area...d..q.�_.sq. ft.
Seepage Pit No._.....,........... Diameter... ...
Z Other Distribution box (/ ) Dosing
Percolation Test Results Performed by..... + .4 a1_e_!!S!......... G................. Date....�
a
Test Pit No. I.....�.....minutes per inch Depth of Test Pit..... __�___.___ Depth to ground water..lY.o.._.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+ ----• ---- -------- -
Descriptionof Soil•--------------•--. -- .--------•-•-.= - ---•-------•-- ------•-•-•---•--••--•--.............................
C. , ,
U ------------- _ -
••••---------------•--••---•-------•----••-••-••-------------------------------......_...._•-•••-------••----••--•-------------•---•-•--•-••-•----•------------•--------•--•------------....._-••-------
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 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 the board of health.
Signed....................................................--................................ -----•-••-................
Date
F.Z � _....APPlication Approved BY................................. _ Z 5 �
e
Application Disapproved for the following reasons ........................................... : __...._„_.. ._.___ - ----- --------
_ --
. � :
.........................................................'--•---------•--------._._..........------------ _•.-• -------•--•----------•-------• ....................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
,/ .
BOARD HEALT '`i�"" ®„r�•-
.......................OF..... ......... ......... ................................
Tntifiratr of Tomphaurr
TH lie Indivi e e Disposal System constructed O or Repaired ( )
�,
by - -•-- •-- - -----A---------------
...---..
Gam"". � � .. ll .
at.................................................... -------------•--.=-
has been installed in accordance with the provisions of � 057he State Sanitary Code as described in the
application for Disposal Works Construction Permit N ......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUN TION�SATISFACTORY.
DATE.......................v�. t �---.---..-•------.--------. Inspector............ ..:... .. .................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
...
No..................:...... FEE.--.....................
��P'
Permissiot�hereby granted............................................
to Construct or�zi'r age ~stern. ,
s stem
" ..
Street
as shown on the application for Disposal Works Construction 1? it o____________ _______ D t -.----...-.--__•.-•-_.---.---------.-----.
PP P ,�.- `..� w � �
............................•-•-------
ard of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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FRANK FRANK a
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CQNERY CONERY
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