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L 0 ION SEWAGE PERMIT N0.
VILLAGE
INS LLER'S NA//MB�E i ADDR SS
�N UI E R OR OWNER
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DATE PERMIT ,ISSUED
DATE COMPLIANCE ISSUED 71
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... ....................O F......................-....--............-----------..._-------......-...------........._.
Appliration for Uiopo.sal Works Tonotrnr#inn Permit
Application is hereby made for a Permit to Construct ('Vfor Repair ( ) an Individual Sewage Disposal
S stem at:
o r.. ..... RP► 1 .. ...._.L`�: +►.Ll ...... .............................
ocat'on•Address or Lot No,
...........MA .Ti�.-_ ..�K�: F wv.sj................ .......... -----(+fit, ... ` ". ...: . i-
Owner A r ss
Installer Address
dType of Building Size Lot____________________ Sq. f t�
U Dwelling—No. of Bedrooms._..Tv�1 _________________________Expansio Attic (r/) Garbage Grinder (qf
Other—T e of Building 14A-•_______________ No. of ersons__ Showers
a YP g --- -----------••--------------P ----------------- Showers ( ) — Cafeteria ( )
04 Other fixtures ______________________ ---.--_----------------_
Design Flow.___J'5______________________________gallons per person per day. Total daily flow____35�. gallons.
WSeptic Tank—Liquid capaci y_I4�_.gallons Length_ 4z_�°_. Width.4=lo" Diameter s/-lI�_.__.. Dep ---
Dis Disposal Trench—No. ._!!Z .. ._. Width_. __._.. Total Len th__ r�....... Total leach in area...
s ft.
Seepage Pit No_____________________ Diameter._._.__._...____._.. Depth below inlet_.._._._._________.. Total leaching area..................sq. ft.
Z Other Distribution box (jA Dosing tank0 Percolation Test Results Performed by •-••--- Date. ..........
Test Pit No. 1. - _.___minutes per inch Depth of Test Pit.....10_....... Depth to ground water.... ...........
(z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
............ -----•••-._...-••---------------------------------•-•-•-•--------•-•------.....-•-----......._._....._..._.._--------....--••-
O Description of Soil....O.�a __ � ..t:;S eJL.
v ----•-•_____________•--••-•-••---.Ca__/_. '.....0 A>u:--.Rj!5
x -----------------------------------•-------____.._.-----------...--•----------------------••-•-•--•••---•-•-••---------------_._-----•••-•-•-••-•---••-•-•-••--•••••-•-••-•••••----•-----••-•--..._..__.
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben is ued�b(y ttih board of health.
i ne ±�'�_ (�g ..............................
----
Application Approved By......
-••- --•.................. .......................................................... ��_- Date
Application Disapproved r e following reasons:••-•--------•-••-•••-------•-•-•------------•----•-------•---....•-•--••-•------•-------------•-....._.__.....
.........-•--•••-••------•--•-•••...................••••-------•---......-•--•---•------.....-------•-•--••••-•--••••--•-----•----•------•------•__________•••-•••-•--•....----_._..---••-•--•----_-•---
Date
PermitNo......................................................... Issued_.......................................................
Date
...............
1 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. ... ....................OF..........................................-------------•
Appliration for M-4puiittl Workii Tnnitrnrtinn frrmlt
Application is hereby made for a Permit to Construct vr or Repair ( ) an Individual Sewage Disposal
_ System at:
..Lp..r-_i3.....F�.tA.ZlFM...0 ._ M: ..... --•------------------------------•------••---------------------------------_-_-_-_--_----------_.-
Location-Address or Lot No.
ARi.I. ...� 11....... ?,` tVt�....._.:-_ - . .__..��('.ra.1 ).... =-.?�:.............. e.jf
LJR
Owner A ress
Installer Address
QType of Building Size Lot............................Sq. feet
U
a Dwelling—No. of Bedrooms_
... ....- ------------------------.Expansion Attic ( Garbage Grinder N
a Other—Type
her f Building
ing --,af/A---------------- No. of persons_:--:------_:--- Showers ( ) — Cafeteria ( )
Q
w Design Flow....575-------------------- ---------gallons per person per day. Total daily flow---- ......................gallons.
WSeptic Tank—Liquid capact y.JbCo..gallons Length... ..___ Width. °." Diameter. 1?_____. De� 1_';: .&SP'
x Disposal Trench—No. _-,VI/ _...... Width.-AAA......... Total Length...Z...A:-----:- Total leachin area...,s/I- `t..___..sq. ft.
Seepage Pit No..................... Diameter.._......___.__..... Depth below inlet.........__.___..... Total leaching a rea..................sq. ft.
Z Other Distribution box QA Dosing tank ( i
Percolation Test Results Performed by...............................
a ---•--•-••-----•--------••---...-----•----- Date......................-•-/-••--•--••----
Test Pit No. 1!�;j9 _..minutes per inch Depth of Test Pit.... ......... Depth to ground water. .........
rJ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ... -•---------------------••--------•-------•--------------•-----•-...-•---------------.........._-----------•---_•----
0 Description of Soil...o."_c __ _IV ub5v_t1............................................................................................................
w
V 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 TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ed bynthe board of health.
igne .................... ...`�``...C .:.�1 ..........
Application Approved B �
Date
Application Disapproved r e following reasons:----------------------•-----•-•-----•-----------------.........-----------------......--•- --...-•----........
..................•------....----•--•-------•------------•-----------------••----•--------......-------...........--•---••--••---•-----------•---------------------•-•------•------••---•-------...--•---
Date
PermitNo......................................................... Issued-........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
C6rdif irtttt of Tomplittnrr
T TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by -�"-_� - .
_ ____�/-�-/--' ---- _
�� /�'V - Installer
at......................................................•--------•--•------....... -----•----------------------.......------•--------------------......------------...---------••-•--•--------------.
has been installed in accordanc witli the ,rov' tons of TI Vhe.State Sanitary Code as described in the
application for Disposal Wor s Const ctio ermit No l r� dated
THE ISSUANCE F THIS CERTIFICATE SHALL NOT BE CONSTRU D S A GUARANTEE THAT THE
7UCTSYSTEA WIL
ON SATISFACTORY.
DATE.....�� r
ncto__.....-••----------------------------------•-----. pe ........ ; .......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............O F.......................... .. 5-9
No.---.........� ... FEE........................
Rsvvs�krkii Tuns#rnrtiun Prrmit
Permissio eby granted...............----
to Constr 5. o �epair (,�a I 'v' ual�S . D' esal System
at ------------=-•-••.
Street
as shown on the application for 'posal Works o ruction Permit N .--!_ ..... Dated..........................................
-------- ---- --- --• ------- -------------------------------
... .........
DATE. Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
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