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AT ION � E �01 G E PERMIT
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VILLAGE
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INST sIER',S N i ADDRESS
j OR OWNER
DATE PERMIT ISSUED � `� -- �'
DATE COMPLIANCE ISSUEDC � �.— �
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THE COMMONWEALTH OF MASSACHUSETTS
d
g I BOAR® OF HEALTH
..._.....................................OF.......................................-----------------------..._........................
ApplirFation for DiipugFal Workii Tonotrurtuau Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at J
.......... -- l�1--. ,. .... fir... ...... '1.. ................................•-......----
Location-Address f ort N
.:.e''--------------------------------
•----- ........_.... ��C _ � e `c vn ✓�......-•-• •--•----
Owner .........._ Address
. .-E>?.........•---•-.....---•---•----------•-•••-•. � ,+-_ ,. 'i �s, tis.. l
Installer Address
Type of Buildin;�_� Size Lot............................Sq. feet
a Dwelling 'LNo. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Q, 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........................................
Test 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........................
Q+, •---•---•-------------------------••-----------------------•-----------..............---•--..................----------._....------..............•.........--
ODescription of Soil........................................................................................................................................................................
x
x --------------------------------•----...--------------------------------•------------......---.....----------
V Nature of Repairs or Alterations—Answer when applicable__4w:-..over __ __LQ.. .. ........... i-f......................._......
------------------------------------•----•-•---•------------------ ----------------•----••---•--•-•-•-•----••----------....--------•----------------------------------------•----...........-•-•-•-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL I''IL . 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue y the board le`lt .
Signed-�J•-• ._.... ------------ �Y.........
�} bate
Application Approved By....... = . �1
. �-•---•......................•-- -...... 1�/ ----------------
Date
Application Disapproved for the following reasons----------------•----...--------------------------------------------------------•------------------------......_
...........................•-•------•.................-----------•-----•••-•••-----....-------------••-•-----..._........--•-••--•---------•-----•-------------------..................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ...........................OF..........................._......._... ••-----•-- .................
Appliration for Disposal Works Tonstrnr#i n Urramt
Application is hereby made for a Permit to Construct ( ) or Repair. :(: ) an Individual Sewage Disposal
Sotem at ,y e4O...
Location-Address o t
e--------------------------------------------------- 1 ¢..7 ---_-__-_--------
Ownerr Address
.........................................................
�n�►�._�� wvs ----,jf --s,
,.a
Installer Address
d Type of Building_ Size Lot............................Sq. feet
aDwelling No. of Bedrooms................................._..........Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of persons____________________________ Showers — Cafeteria
Otherfixtures --------------------------------=----------------------------------------------------------------------•--•-------
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........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ----------------••---•--------------._......----•........----------.........._.......__.......................................................................
0 Description of Soil------------•-•--------•--------•---•--......----•----------------•-----------------------------------------------•-------...-•------------------------._......_...----
x
W -----------------•------------•------------------------------------•----•-------............................. f -- -- _•- ,
UNature of Repairs or Alterations—Answer when applicable Q'w d(�+� 1`7( 1.°ti-�C _. r ___________________________
•---------------------------------------------------•--•---•-----------•-----------------------•-----------.....---•-------------------•----------------------•-----•-••-------.....---..._..-----......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T ITL: y g g p y
5 of the State Sanitary Code—The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has bbe''jen issue by the board ealtb.
Signe r '' _.. {. ll�_ate-/..........
p/ b
Application Approved By.......�<--•. .?
rf' '� ----------------
Date
Application Disapproved for the following reasons:------•--------•------•---------------------•-------•---------_------------••--•--------------______......_.__
Date
PermitNo......................................................... IssuedL.......................................................
` Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�ra�if irtt#r of �nnt�rliaan�.��-
THIS IS TO C RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
------- --------------
'+ Ins er
has:•been installed in accordanc�he provisions Of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_.t .�'"" 41_____________ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
f.' SYSTkM"WILL FUNCTION SATISFACTORY.
` DDATV.....................-----------•-................// L/9)----....... Inspector......................
�
f` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Y
..............O F._.
ct c7
f O,.---?.::�G•.. FEE..15................
Disposal Works Tnns#rnr#ion ..anti#
Permission is hereby granted. - ------------=••--•----•.._..----•---•------•--........-----..........--•_••-......
to Construct ) or Re it ( an Individual Sew e DIs osal Syst
at No.... C�+ em
... �-...-----•-•- - �....- -------------------------------•-•-
� �G` s
It// Street
as shown on the application for Disposal Works Construction Permit No_________________y____ Datede.........................................
�l r a t
DATE......................... ----•-••--•---•••-----------
Boa
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS