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OR
5.......... Sl1 JECT TO •., E....
THE COMMONWEALTH OF MASSACHUSETTSPUINSTARLE CONSERVATION q
a0(�-- BOAR® OF HEALTH Co�lfV99SSION®, f v 3 I
0 r<.vnJ.................oF... /S.?i4.�L, --------------------.........-----
II �
,jok6l� Appliration for Mipatial Workii Tome r�r i��a nmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ` an Individual Se age_ ssal
System at: J 1 1 ��1� 1 .
..... ......1� ....... r...... ..._....... : �'� 353......_ASsfs�?S rna�.3. �T 7
....!
Location-Address or Lot No.
•-^• / ----------------------------------------------
owner L Address
----
In�taller Address
dType of Building Size -Pt_SGt'���-----.Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )-
Other—T e of Building No. of persons............................ Showers — Cafeteria
Otherfixtures -----•----- -----------------------------------------------------------------=---------------------•---------------------------
W Design Flow..........&0..........................gallons per person per day. Total daily flow......_:__h!Yf?........................gallons.
WSeptic Tank—Liquid capacity.,/-iZ-10.gallons Length---------------- Width________________ Diameter----------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area___4_ P-----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. I----z--------minutes per inch Depth of Test Pit....r� _��... Depth to ground water..___6_'�0/-I__.
LL Test Pit No. 2................minutes per inch Depth of Test Pit...AU_?;-------- Depth to ground water..
.............
a ----•------------------------•------------------------------------------....................----....:•--•--------......----------...................._.....-
0 Description of Soil-----c�fr4N f PIVM. .--- ---•-.4f�&12t�:2..------«v----.�A_RK QE ...............
vie C c
W ' r'---------------------•---------------- ------. ----. .
-------------------------------------------- - - -- - - - - ---
U Nature of Repairs or Alterations—Answer when applicable...etW694;f &.—/____-__ ` _L�-................................
................................................0L . .. ............ !1 .........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TT T
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 issued by the board of health.
Signed
Signed•... /✓ ' --- ----....... ' --- _/----F--------------
Date
Application Approved By------le
...t--•-----------------------•---------------••----. ------------------
Date
Application Disapproved for tllowing reasons:---------•------------------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued----------- c ------------.
® Date
,1NO.. FE$............... . ........
~Y_ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'a
......................................... ....................................................................•-
Y' Appliratiun for Bi_qpuaal Works Tomitrurt"tun rrmff
Application is hereby made for a Permit to Construct ( ) or Repair ( v) an Individual Sewage Disposal
System at:
e it J f;" !r ///.- 'j', /, /... f' .,7�V ✓.3 ..1 l:t.r<�J fi� j fl ��-.7 .3
.......-•--•••--------------•••.....- -•• -----•--•--•••-•••-••••-.._..._..-••.. _..__.....__._........_.._...........--•---• ---•-..............-•••--•...•. ...•-
Location-Address or Lot No.
................................................................................................. ----••---._..__...--•------...........----. ._...-............._........_...---•------......._
Owner Address
Installer Address
•!
Type of Building Size Lot__-__-__...................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
r5r d Q' Other fixtures ----------- "-of----t--------------•---------------------------------._...-----_._....--------------------------------•----------...---------
W Design Flow__________of 0......... ...............gallons per person per day. Total daily flow..-__-.___..:.` ....................gallons.
W Septic Tank—Liquid capacity_:a gallons Length---------------- Width.........._..... Diameter-_--_-_.'t...... Depth.................
x Disposal 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 ( )
Percolation Test Results Performed by_____________________________________________________�__._.._-__--__•-•- Date____________•___________ _---.__.
Test Pit No. 1_____4________minutes per inch Depth of Test Pit----_ __._......... Depth to ground water........................
44 Test Pit No. 2............_---minutes per inch Depth of Test Pit............ .... Depth to ground water-----j^.................
Oa •;•�-�-•,�•---•r••Y-1---:-••••r-•v••-�---r•--•-..�.-f•--�•--h••-r-•✓-,----------ls----r•-i-i•�--�----t..............e_--L---A-•-----•-•••c---!-,-�-.'.�._.!_.�.,r--y---�-r•,---•i•.t.1.......----•.._._.
Description of Soil.........-----------------------------------------•_.._:_......_...---------•-••••••--=••-=----------------------f----------------•=--------------------•-------------
U :
Z. ...•-------------------- ---•---•••---•---------••-----------------••--•---•---...-••-•-••------•---•-••-•--••--------------•--------•..-...----------••--•-----...-•--•-•••--•--•---••--------•-----..
U Nature of Repairs or Alterations—Answer when applicable___e/it! �'--_:/ .r=_/�!� l�..
>t+/:7 /lip
-----•--•--•-------------------•----.--..-------•---_...-.•.---•-------••--•--•.-._._......__...___._.-__-____-------------....---•-----...__--..__-.__.--.__-_-_-_-_-_--------.-.---:_......_._...___-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TT T I_E 5 of the State Sanitary Code— The)undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
,�.!��
Si ned .. ..•� �Y.1
Application Approved B Date
PPPP y------••-r --•-•------•--------Date--•---•---•---
Application Disapproved for the following reasons:................................................................................................................
....----•........•••....-...•---------------------•--•••--•--..-..-••-•-•-------•._....-•---------••--•-----•-••--•---••-------------------------------------------------- ............................
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF .MASSACHUSETTS
BOARD OF HEALTH
Trrtifiratr of Toutpliatt
THIS IS TO'CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
o
by-•••••••....L_7<.,j; .. .;? u5=--------•---•-•-----•-•-------------------------------------------------------------•-------•--••--•-••----•---••-•---•---•....•----
Installer
at ,RYA'12 !J i. ?G •� r' .�^= x'!4 N
---------•---------------------•---------•------._.--------------�----••----•--------•._.-...--•-----•-•-•-•--•••--•-•-------......•••---•-••••-•-
has been installed in accordance with the provisions of I'I 5 of ;h State,,Sanitary Code as described in the
application for Disposal Works Construction Permit No.__-_l .__.__._____________________ da.ted_...............................................
'THE�ISSUANCE OF THIS CERTIFICATE SHALL NOT BED>CO-NSTRUE® AS A GUARANTEE THAT THE
'SYSTiM WILL FUNCTION SATISFACTORY.
DATE..._.:`.:..............•---------------•---.....----•---•-•----------.......--- Inspector..................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH s
FEE........................
Disposal Works T11notrurtion Vanfit
Permission-is hereby granted............. :'r _ ..........................
----........................................................
to Construct ( ) or Repair ( �)�an Individual
/Y/vnf SwDisposal System
f / " j leii at No. y G n � ;
Street
as shown on the application for Disposal Works Construction Per •t No_____________.................. Dated....................................
'7 !Board of Health
-� ,,,.__FOR1285I�BBS &.:V1/ARR+EN;ZINC-. PUBLISHERS
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