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LOCATION CAE PERMIT MO.
VILLAGE — — — — — ASS Sa aa-3 d —
1 N ST --E�.S IJ L1, E � ADDRESS
r 5UILDER 5 Q a . AQDR SS
DATE PERIAIT ISSUED �� 7 — — dl
—�
D D.TE COMPLI &MCE. ISSUED, : /�_�" 7 ,
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD ® HEALTH
fV^ ----.OF........:. .... . " ---------------------------------------,......
p ltratzon -for i,i oiittl Worbi Cnowi rurtion j3prnift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
------------- 1°�-�--•--�c� �=p iE•---•--�� --------------- --`11c .6T� t�".............................................................
ocation-,Address or Lot No.
� �11s'E------------- _ -------=-•----•---••---••......--•-•--•----
Ow r Address '^
Y ( c'�°i'�----Y-- v 5----------- �c.C�------- --------...................................=.....................................................
Installer Address
Type of Building Size Lot--------------- -----------Sq. feet
U Dwelling—No. of Bedrooms-------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
PA Other—Type of Building --------------- ---------- No. of persons_--.-..._-.-._.-__--_._.-_ Showers ( ) — Cafeteria ( )
Q' Other fixtures -------- ---------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow-----------------...--.--.._-.._-- ---------gallons.
9 Septic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter-----.---------- Depth._._----_----
xDisposal 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 ( )
aPercolation Test Results Performed by-------------------------------.......................................... Date.............-------------------------..
a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water..-._____--_--._-_-___--
fi Test Pit No. 2-__---__----_-minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.--.---.--.----_-:_...
W1 - ------------------------- -----------------------------------------------------------------------.....................................................
0 Description of Soil------------------------------------------....................................................................--•----------------------------------------------------
..:
U ---------------------------------------------------------------------------------••----•-------•--- ----------..................................................................
W
--------------------------------------------------------------------------------------------- ----:------------- ----
UNature of Repairs or Alterations—Answer when applicable...._----- -- .. f-- - _ . --:---_-- -- - -_---.
--------------- -- °^` -v----`- �• - --
Agreement: " j�/ 41
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accor a� nce 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 been su by the Vboad of health.
Signe
L
Dat
Application Approved By.------ - -- ------ C
Date
Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------------
------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------
/ Date
Permit No--------------------------------------------------------- ¢ .. 7 L
Issued ---- ---- --
Date
No._N.7 to/ Fslm.-. .. .�
THE COMMONWEALTH OF MASSAC`WUSETTS
BOAR® O HEALTH
------ OF - ...... _. .+ ................ ..-.....
Apphration -fox Di_qpviial Works Towitrurtion j3prum
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
dress
it ....... .....Z. dhC� V-"` H!- ....................-----• or Lot No.
Ow r Address
w0 r ' ------------)" !;------- -----------------------------------------
Installer Address
Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
aI Other fixtures ---------------------------------
W Design Flow___________________________________________gallons per person per day. Total daily flow--------------------------------------------gallons.
Septic Tank—Liquid capacity___-___-_--gallons Length................ Width-____---_-.__-. Diameter--------------- Depth----------------
xDisposal 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 ( )
aPercolation Test Results Performed bY------------- ---------- -; --------••---- Date----------------------------------------
Test Pit No. I................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------------------------
----------------------------------------------------------------------------------•••---•---------------........................................................................................................
0 Description of Soil___________________`
W ----------------------------------- ------------------------------------------••-------- --
VNature of Repairs or Alterations—Answer when applicable._________/ ��_____________J� �..!! 1 ____--_ /" /.�
-------------------------------------•----•-----_-_ ......... •------------W6 •-At-ot. ........------- •--------_____-__ __ _-____--•---•-------------_
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 been i ue, by.the boaVd of 11palth.
Si/gne ---------- - ....................... ----
Dat
Application Approved By....... G4ti ------ 7 ` ---J�.
�� Date
Application Disapproved for the following reasons-----------------------------------------=..........................................................................
--------------------------------•----•-•----••------•-----=---•-----•--...---------•-•-•--------------.....-•--•-------•---•-------------------•------------------------------_-••--.•--••----------••••-
Date
PermitNo............................. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
�t�ria OF...... .. .... ... . r' M
Tlerti�ir rrf T , mphatta
T S TO CERTIFY, at the Indivi Sewage Disposal System constructed ( ) or Repaired
by •• ----- -------- ...............................
4 InC alle
at.... _ - ---- -- •---• l i4 4J`-----••-
has been installed in accordance with the provisions of Articl of The State Sanitary Code as es ibed in the
application for Disposal Works Construction Permit No------ _�_.............. dated.w"-._._ .. ...........
THE ISSUANCE OF THIS, CERTIFICATE SHALT, NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
OF..... ... .............
....... t FEE_
Permission is hereby rant _ '"
to Cons t ( ) epa• an I ividual Sewa e D•spos System
st re
as shown on the application for Disposal Works Construction- Per t o __ ___. ____ lted_:'_1 --_.
r !(--
Board.,of_Health,
F •
DATE....---- -- . _.�.:. � :---+------ -------- -'.-------- t
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
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