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EWAG E/ 4W71T NO. ✓
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INSTAL ER'S ME & ADDRESS
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BUILDER OR
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DATE PERMIT ISSUED ic-
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4.
ApplirFa#ion for Uhip u al Workii Tonstrurtion Vamit
t
Application is hereby made for a Permit to Construct (ae<or Repair ( ) an Individual Sewage Disposal
System at: /I H
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� oc tion-Address or t No.
....................................... ------ x ��! / ----------------------------------
.....--------
/� j Owner Address
Installer Address
QType of Building / Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___...f.,Ntt'. .d ______________________Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building 1etx�c ,er.s_€_No. of persons____________________________ Showers ( ) — Cafeteria ( )
Q' Other fixtures __________________________________
W Design Flow..............................._::_'__gallons per person per day. Total daily flow......................4X_1.........gallons.
WSeptic Tank—Liquid capacity_.jkW.gallons Length................ Width__.____._....... Diameter________________ Depth................
x Disposal Trench—No_ ____________________ Width__ ____----------- Total Length.................... Total leaching area________.___________sq. ft.
Seepage Pit No._1rV____._.. Diameter......... _...... Depth below inlet.....[,_r_____._. Total leaching area...2.4?1....sq. ft.
z Other Distribution box Dosing tank 2 P- 71
Percolation Test Results Performed by..__�_ _ V .__ ._ ____ 'l:_2r .- _ ..........
.�__�:_ .dx�.�-�__ Date.-----
`�a Test Pit No. 1___�_4Pl---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_______________-________
P4 •--••---T•--•--------0 -- -- 3 r
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Descrip tion of oil_... S�:_ .. .•- -- g +c ..
c.� Q-1 --2-4---
.......
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W -----------•-------------------•••-------------•---•----------------•-•-•••--•-------•----•-••--------=--------•----------------•--•--------••-•------•----•--•----••-----•••-•--•---•••••----•--•------
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 iIli LE
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been 'ssued by the®broo•rd of health.
Date
Application Approved By-- _• .....s1�
Date
Application Disapproved for the following reasons------------------------•----------------------------------------------------------= -•-=_ -•-----•...._----.
-------•----•-•---------------------------------•-•------------------------------•-----......--------------•••••------•-•--------•-------------� --------•-----•-_...--•-----•----•--•-•---•---
Date
Permit No......................................................... Issued..�! � �_ ......
.
-----------------
Date
l
No--------9-�f•--- - Fizz......�..............
"THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratilan for Klispaii al lVorka Ton .rurtion rantit
Application is hereby made for a Permit to Construct 4o<or Repair ( ) an Individual Sewage Disposal
System at:
a_
od
Voclion-�lddre s or�°t No.
/" Owner Address
a •----. 1.�� ._.. �1�= ...............•------•-••--•-•--.._..-•----... ....................................... ..
Installer Address
Q Type of Building /l Size Lot..................V--------Sq. feet
U Dwelling—No. of Bedrooms._"�h ..rAt_______________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of BuildingPIP of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ----------------------------------•---- -
W Design Flow_______________________________.,5�,7..gallons per person per day. Total daily flow_-__._.______.____.._. . �j.........gallons.
WSeptic Tank—Liquid capacity. 0w_gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No_____________________ Width__ _.___._.___.___ Total Lengt=h_................... Total leaching area._..................sq. ft.
Seepage Pit No._0410P-_______ Diameter........ .__.___ Depth below�hlet___ ............ Total leaching area___ _ ....sq. ft.
Other Distribution box (r,.�''f Dosing tank ( ) 6+, ./� :. 2 41"70
z 2 .7'P
'� Percolation Test Results Performed by..__�. _ __ � /z,M�d__.____ Date.___'`____ ______________________
Test Pit No. 1.__ _ .__minutes per inch Depth of Test Pit____________________ Depth to ground water__________-___________-.
f� Test`Pit No. 2................minutes per inch Depth of Test Pit.;___._._._._______. Depth to ground water_______________________.
Descripti?n of 4od- " /� '......- cir " "'* r
x
U
W ....................•............................................................................................=................................------•---••-•-------•-----•-•--•---•---•---•-----=
t.
U Nature of Repairs or Alterations—Answer when applicable____________________________ .,
.----------• •-•-----• ---_.
Agreement R
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 2
the provisions of TITL i� 5 of.the State Sanitary Code—The undersigned further agrees not to place the system in
g++ operation until a Certificate of'`Compliance,has been issued by the }o rd of health.
S d-- x�� J ------------------------- " E€
Date
Application Approved By__ ✓.' `
Date
Application Disapproved for the following,reasons:-----------------••--=----------••-•-•---•----•--------------=-----------------•--•------ =•-•••--...._--•---
----------•----•----------•--•---------------•---------------------------------------------••-------------•-------------•-----------•----..............................................................
Date
Permit No.........................`: ----- Issued._.j
Date
THE COMMONWEALTH OF MASSACHUSETTS
r BOARD OF HEALT_
..
............. ,;OF........ .. .. ........... .-- ..... _............_.......ss..........
%untifirtttr lad woutpliFanrr
THIS I O CJ,E at the Individual Sewage Disposal System constructed (�of`kIk paired ( )
by °' ............................................. �`Aj r/rJ/} --/J.--- ;
at__-�_.. 9 f""b+lAY� �`� 3 �_�0/n aller � !� V IFS�� `=Y._�.�_.!::�.%G Q..
r:
has been installed in.accordance with the provisions of TF 5 of The State Sanitary Co s described in the
application for Disposal Works Construction Permit No._:%�__........tt__7________________ dated--`'_ _ '----'�
THE ISSUANCE OF THIS CERTIFICATE"SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL UNCTION SAT'[ FACTORY
DATE... C./ `< `�...........L' ._. Inspector. _....__
- ..'•;ti,,c,mra„;c
THE COMMONWEALTH OF MASSACHUSETTS
P
BOARD .OF HEA T
4 i 7
o
Ifs' ...............OF........ .........._._._...-.___-"_"._-_-__-__-__...._....._...._._.._.......
No......................... FEE........................
�r at� rk !�&
�rairrn rrnti�
Permission is,>he"reby granted_____ ' '
to Constr> t or Re it ) Indytiuk Sewage DI osal stem r
�e .
-4. .-A�
at No._0 •� ',� t!r2t,�. 1. 7 . +� y .............
ram` "s. Street -- 1-1-. 0.-
as shown on the application for Disposal Works Construction 'Pe - No._ :__ ___. . __ Dated_____f__:____.____......................
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y%............. � .........................•
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,� Board o 'ry DATE""-- �-4;-••71`•.............................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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