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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,-- ------- OF- ,? :...... ................................
Appliration for R-po al Noibi Toustrurtiun Permit
Application is hereby made for a Permit to Construct (p< or Repair ( ) an Individual Sewage Disposal
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-=oaajn- d A e j or Lot 1Vo. o
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ne'r ..............
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J Installer Address
UType of Building Size Lot.__.l..Q..O` ......Sq. feet
�., Dwelling—No. of Bedrooms... ...................................Expansion Attic Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures� ................
W Design Flow..........................k..�....._�allons per person per day. Total daily flow............... U "r -----------gallons.
0' Septic Tank—Liquid capacity1��o_l�gallons Length................ Width................ Diameter................ Depth......,.........
W Disposal Trench—No..................... Width....�.,tr}...... Total Length.................... Total leaching area....................sq. ft.
�Seepage Pit No.....I-------------- Diameter&/, .___..__ Depth below inlet.....A(_........... Total leaching area- .,7—..sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1....�-----minutes per inch Depth of Test Pit_________________••- Depth to ground water-------------------------
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------------:______
a ..............
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ODescription of Soil.............. -s.- .-----•------•---------------------------------------------------------•------------------------------------------ `.
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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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en issued y th oard o lth.
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Sign ..... .--- -- •---= ...... ....................................... ..�_
ate
Application Approved By...... 1--- ---- - ---- ------ -----M- -- ------- -------------------- ----- ____�_�� ?'�
_ Date
Application Disapproved for the following reasons:................................................................................................................
.........-•-•-••-•----•..............•---••-•-----•-----•••-•••••••-••----••••••-•••............------....-••••••-••-•••••......--•••---••-••••••••••••-••------•---••-•-•-•••••••••••-•---•-•-••------•
Date
PermitNo......................................................... issued.........71 to ......................
Date
THE COMMONWEALTH,OF MASSACHUSETTS
BOARD OF HEALTH
......._......CIF..... ..
.... . ....�7......................
Apphration for Disposal Works. Tottstrurtion Prrutit
Application is hereby made for a Permit to Construct ($,/) or Repair an Individual Sewage Disposal
System a�
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.. .. .......... ...........................
Locatio i dress or Lot No
/76
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j% -ZIA-
.......... ............... ..................... .............. ............. ............. -------------
Installer Address
Type of Building Size Lot./0 .4W........Sq. feet
U
Dwelling—No. of Bedrooms........a................................Expansion Attic (4--f Garbage Grinder
aOther—Type of Building. ............................ No. of persons......... .................. Showers Cafeteria
Otherfixtures ........................................................ ...................... ......................................................................
Design Flow...........................x�_.Q......gallons per person per day. Total daily flow..............4;?—_ ............gallons.
Ix Septic Tank—Liquid capacity 7_10gallons Length................ Width......._._...... Diameter__........_..... Depth.._.......__.._.
Disposal Trench—No..................... Width.....r . ....... Total leaching area....................sq. ft.
...... Total Length.......
Seepage Pit No..-.-/............. Diameter4/t/i-.',,...... Depth below inlet......��-;......... Total leaching area:J�.An.sq. ft.
Other Distribution box ( ) Dosing'tank ( )
Percolation Test Results Performed by...... ..............................I................................... Date........................................
Test Pit No. 1....1 1-:".....minutes per inch Depth of Test Pit..................... Depth to ground water......_.._..__..___-_-_.
;T4 Test Pit No. 2................minutes per inch Depth of Test Pit:....._............. Depth to ground water.._................._...
04 .......... ........ ...........................................................................................................................
0 Description of Soil.............. ............. -------------............------------------------------*--------------- -------------------*--------------
�4 -
................................................................... ..•
...... .......................................................................................
U
.................................................................................................................................... ....................................................................
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 Article XI of the State Sanitary Code— The undersigned further agrees rot to place the system in
operation until a Certificate of Compliance has issued by the board of health.
Sign . . .. ............... .. . ....................... 7 .2
.............
...... . ..........
Application Approved By
Date
Application Disapproved for the following reasons:....................7....................I.................I..................................................
........................................................................................................................................................................................................
Date
Permit No......................................................... Issued. 71Z...... ...
te ..................
Da
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Q11 HEALTH/
/7... ..........OF....... ......
........... ............
Tertifirate of Touts haure
TTS I 'TO CERP, Y► �T t the Individual Sewage Disposal System 'constructed or Repaired
hm
by.........W....
-- - -- --------- - ...... - ---------------------------_
.. ......... ........... ------------------- ---------
.. ..... ....
at . ....... ... ...... . ......... .............................................
has been installed in accordance/with the`p
row ns olArticle/X of The State Sanitary Code as described in the
application for Disposal Works.Construction Pertnit No......................................... dated.__7/z. -j-, 7-/ �------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM
' Y.1�1. FONCT1 . SATISFACTORY
DATE. _/.. . .. ........... ..'.'....... Inspector. 11 .......
THE COMMONWEALTH OF MASSACHUSETTS
H E Al�.�,BOARD F
F ...................................................
No.....2,
................ FEE..2................
IN jaml orks TZ- 15k, Iffivia Vautit
.. ... ..........................................................................
hereby granted... . ...........Permission is
to Construet Repair, ndividualo Sewage;Di osal System
L-161 Xe-;e
at A_/ ..
....................... ... .... .. ............. ...........r
Str ect
as shown on the application for Disposal Workwonstruction ReIrnit N Z).. Dated.._d.............
'0, .........................
. . ..... tA
... --------- ..........................
Board of Health
DATE........ ............ ......................................... ..
FORM 1255 HOBBSA WARREN, INC.. PURLISHEPS'.