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THE COMMONWEALTH opmAssxc*ussrra
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Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
go rner Address
�4 Installer Address
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' Other 6x
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Dcxigo Flow................ 06. gnUoosper person per day. Totaldaily flow-..-_-._---------gaDou,.
Septic Tnok--Liquid Length................ Width'---_. Diameter................ Depth--.---
DisoosaTrench �V�d� Total -.-_--- Totalnrcz------.sq. h.
b�m" Total &achiggarea'''--'_�y. b.
Other Distribution box \ / uvxoqg tuuu \ /
~~ Percolation Test Results Performed by........................................................................... Date-----------.---'
Text Pit No. l----------------miunteopczioc6 Depth of Test Pit.................... Depth toground water------------------
[14 Test Pit No. 2...... .........miootespor inch Depth of Test Pit-.-------- Depth to ground water------------------------
---------------------------------------------------------_-----.--.---____-----.-_--_-''----_-_-. �
0 Description of Soil. ' .
. ....... -__--_-___-.-_--__-__.-_-.-----.-.. � �
----------------------------------------------'_.0�'_-_-'--_-'-_--------------_-.__-------'---'----
'- Nature of Repairs or Ahcrur�oo--Answer when applicable-_''--'--'-'--____-'-------- --'.
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| ------------------------------------------------ ----------------------------------------------------------------------------------------- ......... ----'--'-'--'---'-
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` The undersigned to install the uforcdeucribod Individual Sewage Disposal System in accordance with |
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the provisions of Article XIof the State Sanitary Cod -The undersigned further agrees not m place the system in
operation until u Certificate c6 Compliance has been issued by the bo of health. ` .
| Signed ...... ��_ ------------------ _
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�� �6o rxuxomx�-_-'---_-'----_'-_-._------.____-'_--'--- `
) Application '' ' following `.
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Permit Iouo�l_���� ���� --_--- �''------,------------'-'--- -�--�a�r-"--'»r--'
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No.....-Z- -a..... Faa..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
.----.OF.......:.. .. .. .:...._:- -.::. -- - ..........-...
f Ayy,, Iir #��rt� fnriu�ttlrk (� tti#rttr#tott rrnii#
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Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal
Y
st at
ation d a or lot N /
.........
ner ress c;� .address
a ---••-•------------------------•-•- ---------------`C--------------••-•----•••-•-----• -----••-•-----------------•-•----••----.-.....--••--•-•••-•---------•-----•-•--...----------------
Installer Address
d Type of Buildingf"" Size Lot_ `s"`" _______Sq. feet
:. Dwelling—No. of Bedrooms.-___. .............................. Attic (X) Garbage Grinder ( )
Other—Type of Building -------------:_--_____.---___ No. of persons-------------------------------Showers ( ) — Cafeteria ( )
Q' Other fiat es -- •---__-----
d
W Design Flow::____--_______- 0________-_______gallons per person per day. Total daily flow---___________________________----_._-----gallons.
- Septic Tank—L`iquid capacit gallons Length................ Width---------------- Diameter-----.---------- Depth_-------------
Disposal Trench—No._:_-.t_.p __ _____. Width.................... Total Length-----___--__ ----. Total leaching area_.-_.-:. _-:.......Sq. ft.
Seepage Pit No.� 1f 645iameter____________________ Depth below inlet.................... Total leaching area------.-----------sq.-ft..
z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.--- Date
W F '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------------------_....
...-.
` -----------------------------------------------------------------
Description of'Soil -------------------------------------------- -----------------
-•--- ............ . --------- -
+,. W ------------------------------- ---------------------- ___ ______-__-____-_-__--______--_.
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U Nature of Repairs or Alterations 'Answer when applicable."............. .---------------------------------
-- •-------•---•--•------- ---------------------------
Agreement: '
The undersigned agrees to install the aforedescribed Individual Sewage Disposal. System in accordance with
r the provisions'�Tf Article NI of the State Sanitary.Code— The undersigned further agrees not to place the system in
operation until a Certificate:of Complaance"has b`eeri issued by the boa of health.
Srgned._....__--
A s lication Approved By. 1- _ r• � TD �---- - _
,ea. Date
Application Disapproved for the following reasons`'_________________________________________ ___________________
t Date
Permit No.•-116 Issued `" 'y
Daft
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;. THE COMMONWEALTH,OF MASSACHUSETTS
S
/f BOARD OF EALTH
+nrr
............. .. .....OF.......... ...
.:.....
4 , .., Trx#tftra#r of Tilutpliattrle
THIS IS TO E TIFY, T the.I dividual Sewage Disposal System constructed ( or Repaired ( )
by............................ • ---•-- .....................................................................................................................
4�7
_ ---Installer
has been installed in accordance with the provisions of Artic I f The State-Sanitary Cod y� a�des7i}yd in the
et--- . f 1/
application for Disposal Works Con struction,Permit No................�-------- �____:_. dated_._._______.________.____:.___._.._._..---.__--_
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTRON SATISFACTORY.
DATE------, ," ........................................ Inspector--- -... :- ----......---- ----- ............. "•"----
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.-.:.�,b%;.,..,, ._ . h � 4 µ •, ,ram � -. `
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF....................
No.--- '.._. FEE-- -•--•--...•..... .
Permission is hereby granted rk ------------------------•---••-••----------------•-----------•--......--••----------•----•••••--.-...-•--
to at Const�r,,,u�t ( ) or Re� ( ) an div� al Sewage Disposal ystem
Street 9•
as shown on.;the application for Disposal Works Construction Permit No----------___________- Dated.......................................... "
Board of Health
DATE-----•--•-•.......................•-----•-•--•--- ......--•-•-----•----•-
"`F FORM It
to HOBBS & WARREN. INC.. PUBLISHERS
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LOCATION: SEWAGE PERMIT NO.
VILLAGE: AMA
INSTALLER''' S NAME & ADDRESS:
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BUILDER'S NAME & ADDRESS:
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DATE PERMIT ISSUED:
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DATE COMPLIANCE ISSUED:
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