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LOCATION + [c) ( SEWAGE # Z
VILLAGE—MA c54oV� iM;big PA
ASSESSORS MAP & LOT
INSTALLER'S NAME & PHONE NO. .7, 065(oll
SEPTIC TANK CAPACITY S
LEACHING FACILITYAtype) Z (size)
NO. OF BEDROOMS '-J PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: a
DATE COMPLIANCE ISSUED: ® '7
VARIANCE GRANTED: Yes No
f (7 �ro
J- �
AISESSORS MAP NO: AA
PARCEL NO.-
...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i.
/n, OF.....5dAfL0.&,&6..............................................
Apptiratiou for Bhqpviiat Works Tonstrurtion Vamit
Application is hereby made for a Permit to Construct (/10) or Repair an Individual Sewage Disposal
System at:
d o I .. ........ A 1 A....../.(.
......................................
Location 0 t 0.
..... � ............ ....... --Own I Address
,�>
,Oar . . ............... ......&AI
........ .........
Installer Address
Type of Building Size Lot..V` .g5_7........Sq. feet
U Dwelling—No. of Bedro oms--3... .....................Expansion Attic Garbage Grinder (
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria (
Pa
Other fixtures ......................................................................................................................................................
Design Flow.............:55......................gallons per person per day. Total daily flow.........330.......................gallons.
1:4 Septic Tank—Liquid capacityJ000.gallons Length......-......1 Width... ........ Diameter________________ Depth...._.........--
Disposal Trench—.NTo. .................... Width`.................. Total Length.........%---------- Total leaching area---_-----_--------sq. f t.
Seepage Pit No-------------I....... Diameter-----00............ Depth below inlet.....Q............ Total leaching area..100........sq. ft.
Z Other Distribution box ( ) Dosing tank (
Percolation Test Result Performed by---W_M.�---- ........................... Date...'Ah'51%-----------------
Test Pit No. I..... ?V-----minutes per inch Depth of Test Pit.................... Depth to ground water-----------------------
Test Pit No. 2....4.._..._minutes per inch Depth of Test Pit.................... Depth to ground water.._......_...._....____.
.............................................................................................................................................................
0 Description of Soil....0..:i..X j.......T420...11....5uh4al.......................................................................................................
................................... ........ ...............................................................................................
.................................jV0...wadz ...........................................................................................................................................
U Nature of Repairs or Alterations—Answer when a livable.___________________________-------------------------------------------------------------------
................................................ ....................... ............ .................... . . ............................................................
Agreement: agrees
The undersignc� s o ,in all the afo i ual age Disposal System in accordance with
L.L IT
the provisions of Ti 5 of the St e Sanitar 0 he u e j ed further agrees not to place t syste�/'in
ice
operation until a Certificate of Compliance has been by 0 of health.
Sid...... ....... .. ........................ ........................... .... ........ ..............
ApplicationApproved By------. .... ............... . ............................_,Z............. ......... ... .................................
Date
Application Disapproved for the following reasons:................................................................................................................
..........................................................................................................................................................................................................
Date
Issued_.......................................................
- Q'l
------------_------
Permit Ne_���
Date
r. ,
Not3.... ..... ._......_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
----------r Ll 1-------. -... --------------------------•--........----•-•---
Appliration for Disposal Works Tonstrnrtion Permit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
......h-----.j �i '� a� . ..A!2)?.......�s.:�P. 1"�a�? t . 1' ,��a...................................
Location-Address - r No.
�.el ..., ----------------------- 1` �u4rr .... r --------------•------------- ..........
Owner Address
Installer Address
UType of Building Size Lott-tA.M-.7__.__......Sq. feet
�. Dwelling—No. of BedroomS__3...&t.R.:......................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------•-•--•••••-•---------------•-•--•---•-•---------•••--•-•---------•-------•--.............--•-
W Design Flow.............5...........................gallons per person per day. Total daily flow........3_3.a........................gallons.
W Septic Tank—Liquid capacity/004)_gallons Length............. Width... Diameter................ Depth...........
__...
x Disposal Trench—No. .................... Width...._._............. Total Length_.......t........... Total leaching area....................sq. ft.
Seepage Pit No-----------1-------- Diameter...-j:............. Depth below inlet---A9............. Total leaching area.0 ......... ft.
Z Other Distribution box ( ) Dosing tank ( ) I
~' Percolation Test ResuI Performed by..U!. ...... La!t h,11_r ............................. Date.-F h.� .�6.__.....___.._.._..
.....minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 1._.. _. .
fs, Test Pit No. 2---0t.'_........minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •---•-•..----••..._.---•-••-------•...----•-•--••...............•-•---..........._........••-•-.............................................................
ODescription of Soil...Q•-=--•a'=-•--.....T ...I.....5M_b.W.,Z.........................................................................................................
x !�.t_l1th.._�?cA1.
U -------d---- --------------••---------------------------------------•-------------•-•---------------••--------------
------------------------- �f(� ��' - ...................................................... ........-•-----••----•---•---••---------•--------•-•--•--•-•---------•--------•-•----•
U Nature of Repairs or Alterations—Answer when plicable................................................................................................
............................... ............� -• ---- --------•---•--•.... ------• •--•---•----. -------------•--------------------------------••--•--•---••---
Agreement:
The undersigne agrees to i tal the of a scr e i ual age Disposal System in accordance with
the provisions of I-1,LE of the 5 to Sanita o e ,The u d ned furti:er agrees not to place t syste in
OP eration until a Certincate of Compliance has been issued by d of health. Ad
ed..... " --••••---••----- ...._....
Application Approved By...... •.. ................ .. -....._... I.
Date
Application Disapproved for the following reasons------------------•-------------•-------------------------------------- ........................................
----------------------•----••---------......--•---....----------•-•--......•---•---......._.........•-•••••....•---......_.....•-•••-. ---••-----••--•••-------•-•--------••---•--------•••----.........
Date
Permit i ..-_:...'. '.:_.T....v Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TC�I<c�Y1.1...........-OF..... . 'CR .....................................
(Irdifiratr of ToutpliFancr
THIS IS, TO CERTIFY, That the Individual Sewage Disposal System constructed �O or Repaired ( }
by.....r' .A b 1L1' - ••_.._ .......•--.....•------••••-
.................
Ins
/ ! /�- . 1_
ller
at.... ----._�_U[!�Y1 !_f .__ _ ?�Y_�_...4 !C `�=•1ta
has been insmiled in accordance with the provisions of T i T i.6 f The State Sanita C de ass described in the
application for Disposal Works Construction Permit No. _.... JJ dated_ .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT O ED AS A UARANTEE THAT HE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Cf1 n ..............OF..... ���.r'l ?�G?.......
FE ..
Disposal lVorks Tontrurtion rrnnit
Permission is hereby granted....K.Cl k 1L........ .t -----------•-----------------•..-•--------.--..--.------.--------•-•-.------.-.
to Construct (xi ) or Repaij ( ;) Individual Sewagfe Di osal System
at No.... .... !?1.�1'1.�f� ...: ?[z:k.._.1,,`!� .1' he
------------------------------�`'� j�/� .._.. .........
Street
as shown on the application for Disposal Works Construction Per ___________ jate .___.____��`_? _._....,.
V�
G= Board of Health
DAT7E.�C_-,.�_-•+Q f I.�. R.�
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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