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LOt T ION 3 S E W A G E PERMIT NO.
VILLAGE
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INSTA LLER'S NAIVE & ADDRESS
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B U I'L D E R OR OWNER �w�✓ '�
AT P RMIT ISSUED
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARDOF HEALTH
Appliratiutt -fur M-4puuttl WorksZowitrurtion Pprutit
Application is hereby'made for a-Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
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CL � �V( 9e_"7-Address or Lot Na..
------•---==------•------••-----._r_..._..-----•---................................ --•----•--------•---------•----•----•--•-•--••----••••---•---•-••-------------------------•--•----
Owner Address
W -- ---- ...................................................... --------------------
Installer Address
d Type of Building/ Size Lot_____________________ ______Sq. f
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
P4 Other fixtures ---------------- -------------
W Design Flow................ Mons per person per day. Total daily fl w_____________________ __ ..............gallons.
WSeptic Tank�Liquid capacity/ gallons Length---------------- Width_- ._.-.__- Diame r__-_ _ _. Depth.-__.___-__._--.
Disposal Trench—No_ ____________________ Width____________________ Total Length___,_ _. Tota a--------------------sq. ft.
x p
Seepage Pit No--_--_------------ Diameter.................... Depth below in t__...h...________.__ To 1 leach
Z Other Distribution box ( ) Dosing tank ( ) ® � 40 (one
a Percolation Test Results Performed by--------------------- •-----------•------...-•---.....-------------------- Date----------------------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water_-_-___________-___-----
G%, Test Pit No. 2........._......minute r inch Depth of Test Pit.................... Depth to ground water___-_____-________--_-
0 Description of Soil---- ------------
x
W ---------- --------------------- --------------------- 3 �•----•--•---•---
Uture of pairs or Alterations—Answer when applicable._-__` -__. --- r V '�"s�g
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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 b n issued by the board of he h.
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i ate
Application Approved BY ." :.. _.. -- -- -- .
Date
Application Disapproved for the following reasons________________________________ ___._______________________-___..__-._-_________._.____..__...______
•---------------------------------------------------------------------------------------------------------------------=--------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
No..---_/..•.................... Fug. . ........................
THE COMMONWEALTH
COFUMASSACHUSETTS
B0J'1�D ®I� f-1E{�L�
.. ! .................
A.V41 iraatinn -rear Uiipniittl Workii Tonstrnrttnn Prrutit
Application is hereby'made for a"Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
SyAprn at:
sY7 ; ,
. �%' ---•---•----.--
� rLRcgit�oA Address or Lot No.
. • •-•-• �................................................. .••----------•---•--------•--•----•••-•-•-•....------•-----......•...............................
Owner Address
a .................. - ......................................................
Installer Address
d Type of Builditor" "" Size Lot............................Sq. f
Dwelling-No. of Bedrooms.--_ ____ ________________________Expansion Attic ( )" Garbage Grinder ( ._
Pa-, Other—Type of Building ............................ No. of persons.---------..,---------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ___.. _..__
d -..._....__
Design Flow__ illons per person per day. Total daily fl w........ f ----..gallons..
WSeptic Tank Liquid capacity/j�atlIons Length................ Width.- Diam .,� Depth-- --
x Disposal Trench—No- ------ ____---_ Width-------------------- Total Length----- ---- Tota ea----•---------------sq. ft.
Other Distribution box ameter___________________ Depth below i et..... ... To 1 leach• ,� ;r�eq. ft.
See a e Pit utionNo _.._.__ ( ) Dig Dosing tank � ��Pf
`-' Percolation Test Results Performed b `---- -_ Date_.
a Test Pit No. 1-------_........minutes per inch Depth of Test Pit.....................Depth to around water-----------._-.--.----.
f� Test Pit No. 2----------------minut er inch Depth of Test Pit..................... Depth to ground .water-:..-.----_._.._------.
-••----- .................................... -
O Description of Soil----------- --- -- -
U --------------------------------------------------- --- . --
W ------------- -------------------------------- -------
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V ture of pairs or Alterations Answer,when applicable __-- ---- -- ----------- -
------------------ :-- - ---- j
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 b en issued by the board of he h
Ile 10011'
Application Approved BY--- `- --- + "" *'
Date
Application Disapproved for the following reasons-................................ ------•----------------------------------------------------------------
Date
.Permit No.......................................................... Issued........................................................
Date
"-THE COMMONWEALTH OF MASSACHUSETTS
BOAR F HEALTH
.......�..............oF.:.. ... . .:Z ......... . ...t:c....................
T,rH �lerti�ir�atle gf�f��ua�li�anrr
IS IS T61C TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired `
bY...4 .--... _----- ...........
-----------------------------
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at.. �I--6_dY�l " ��--� ..... -- `------- ++�•�..5 -- � ,!,
has been installed in accordance with the provisions of A I of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. .. _...../_! �______--__- dated .: +7.,t ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION .SATISFACTORY.
. DATE.......... - --- ---7 .........
:.......... Inspector---- •%___--_.C--------' (-Gaff-- -`
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEAETFk
-- OF.. . ..----- . ...---... .. .
NO...LLc. FEE�- ,'
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Permission is hereby granted:. •-----• ... ........... -------------•-....-----------•-----•----•--•--------••------•----•-.
to Cony" ct ( ) or Repair ( 'anndyvidual a e spos Sy e
Street «�
as shown on the application for Disposal Works Construction Per. - o-------------- Dat __ f: ',
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�j *� oar La of He51t `
DATE. '_`_!.- 7_ ',
FORM}-1255 HOBBS & WARREN. INC.. PUBLISHERS
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