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KEEPING YOU ORGANIZED
No. 12534
2-153LOR
'UITAFFMS RY�� MIN,RECYCLED
Wn=VE CONTENTIO°k
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SM1290
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~^ASSESSOR'S MAP N0. PARCEL
VOCATION / SEWAGE PERMIT NO.
�2 pica
VILLAGEO
INSTA 1. 1 'S N� AME A ADDRESS
t Tu
r
(�_e U I L D E R OR OWNER
DATE PERMIT ISSUED � o
DAT E COMPLIANCE ISSUED
s.
47
Tl-
Ay
I�
1 !'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...TV w_�..........I......OF %-,.c.......................
Appliration for UWpoiial Workii Tonstrnrtion ramit
Application is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal
System at: �\
............. ..---- ...........EWA ...• � I''If ..... - ... .....
Location Address or Lot No.
........ ..... .........
Owner Address
_y
Installer Address
UType of Building Size Lotbj.z�...........Sq. feet
Dwelling X No. of Bedrooms............3............................Expansion Attic�l(b) Garbage Grinder ,�)
PL, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures -----------•--- ------•--•----•---•-•------•-
W Design Flow..............SS....__.........--__gallons per person per day. Total daily flow..._.....S 3 ...__..._._..___....�1Ions.
WSeptic Tank—Liquid capacity tODO.galIons Length................ Width..........27 Diameter................ Depth.�-.........
nch—No......3...._.... Width..:...+_...C7Xotal ( 1 leachingarea.�45- . s ft.
x �R es Z - 3�° q
Seepage A No..................... Diameter---•_----___-_______ Depth belo i et•-_---.__........... Total leaching area..................sq. ft.
Z Other Distribution box (x) Dosing tank ( )
Percolation Test Results Performed by........ x� -r?..�...�._. .E........... Date....• - �-� �8'4'
Test Pit No. I....'2/...minutes per inch Depth of Test Pit-------P_....... Depth to ground water..-_dv1_---------
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 .................. -------••----•---------••----•-•.......................•----...-----••----........----...........-----------...........---•-......
D Description of Soil - ---!-�l- Sv�3 of
U ..............•----•-••----•-•--------.....':.8...--•C��=" --•H ..-----`�--�...D--------------...-------------••---•-----------........-----------•--•---•----
= --- ---------------------------------- ----------------------------•--------
U Nature Re airs or Alterations—Answer when applicable.___.,.��A615.1...............?���!�!�
-� ti! Iv "7/1z-CPfi"Ti y�3 .... ... C � T� `� 1. ..�!s.cz `-T...............�.�LSc4.o/`
Agreement: S 0.3 f az� !I�} �'r1tc r�cc �►�1we�— Vie- `
The undersigned agrees to install the aforedescribed Individual Sewa&1jispos1 System in accordance with
the provisions of iI.I.L 5 of the State Sanitary Code—The undersi e of to place the system in
operation until a Certificate of Compliance has bee sued y the b r • - / -
Signed �. . --- -- ••. -• ...............•-•-••--•--•-•-•--
Date
Application Approved BY--•-•-•-...��.......: _� � ........................
Date
Application Disapproved for the following reasons:.................................................
-------------------------------------------------------------------------------------------•---------•---•------•-------------•--••--•-------••••----------------------•-••-•--------•-•----•--••-•••-•-
Permit No..._........- .P -. Issued_ Date ...
Date
.-......♦...........................................................-..........................0..0..*..see 00-000000000.00 r..*.*.1
THE COMMONWEALTH OF MASSACHUSETTS
ti
_ BOARD OF HEALTH
�.Q.. .."�...................OF... ..A. .N.s.7.A. ..�-.................
�rr�ifirtt�le ,af f�unt�li�anr.�
THI 0 CE TIFY, That..,hee Individual Sew;,1 Disposal System constructed ( X or Repaired ( )
by............ .!YJ�.►_..'�...._.._lu GK f. f' --•-----------------------------------------------------------•---------------
9 ( Installer
at..................................... ... •-•- �
has been installed in accordance with the previsref's of TIT F 5.of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ __ _` dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.................................................................................... ,`
4w.
Z ._.... •_ FEs.-.'... ..............._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ,. (,. ........................ ..... .. R
Applirotiun for Disposal Works Tonstrtirtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
_ Owner
-----------•-- •-- ••--'
t r� 1 --•-1. ), M. =-'' hLv�G ,lam rly_ �JtY' j� A
Installer Address
UType of Building _ Size Lot';_'.....................Sq. feet
Dwelling�No. of Bedrooms...........................................Expansion Attiq`(, ) Garbage Grinder jO,,)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures
W Design Flow.............. ......................gallons per person per day. Total daily flow........ ...........................gallons.
WSeptic Tank—Liquid*capacity! Length................ Width................ Diameter---------------- Depth.A..........
x Disposal Trench—No._.....^........... Width..... =.'..! TotaleLength..'_.`'__._E....%*otal leaching area. .., ....... ft.
1 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (X) Dosing tank ( )
Percolation Test Results Performed by.......�.,.................................................... :- -t r -
,-� -------•---• Date...... . ` ----••----•-••••--.
Test Pit No. 1------2a ::_._._minutes per inch Depth of Test Pit------f_.......... Depth to ground water---L'Z...."_..._.....
4_4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
OW ------------------------------------------••--------•-----•--------....---•-•.....-----'-'-•'-------.........................................................
Description of Soil........•...............f
........................-.......................................................................................... •........................'...............
._...---
---------------------------------
U Nature of RSpairs or Alterations—Answer when applicable.-.- I N! -(S/IU ` _ t� S
1 - ------------------•------•-.T
�•,,..,.e _.. Fl.. '.-..-C: �J.c_!'n_..... �4O/�p .�N(/ C ..................... f/J yU a 7 i (�s%4.,v�
r �a ...... �
- - -------------------------------- ---
Agreement: 1 L`.�i n e �e, -'� cc <' cy.- �,e" I J �f1 n/
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigne`d,further agrees not to place the system in
, ` f
operation until a Certificate of Compliance has bee ssued y the boa /,of/health./
Signed.. .( ...:. J : ...---- ... ................................
_Date
..Application Approved By................ . � ................................................. ��._._y /. _.......
Date
Application Disapproved for the following reasons:.............----•----•--.....--•-------------------•----------------------------------........................
---------------------'--.....-------'----•---•-----------•------.......-----------•-----••----------...---•---•-------•------•---•-------•--•--•-------- ...............................................
- yPermit No..... •=:_..._•-� ------------- -----'-''-'-' Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1
Trrtif irttte of ToutpliFanrr
THIS IS TO CE)?TIFY That the Individual Sewage Disposal System constructed ( )<� or Repaired ( )
------'------------------------••'•-•-'.....--------"-•••-•---•-----................__.-----'--•----••-•-•---••--
1 Installer
at-•••-••••...=`5---• -� = � -- .. -----------------------------------------------
has been installed in accordance with the pre�v�isi6ns of TIT. F of--Ihe State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__.�:::__ . • — f!= dated---------------------------.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
e
THE COMMONWEALTH OF MASSACHUSETTS
V
BOARD OF HEALTH
.......... -
N � t............OF.....,E w , ., - h r. t._. c. Jam, -rs =^'
FEE.._..... .......
to�ruuttl Turku T nutrurtion rruti :• - i- 7
Permission is hereby granted :__ --�==-=f------.............=•--`•---••.••. t............••--...'�._....
to Construct ( v-)+or Repair ( ) an Individual Sewage Disposal System
atNo................• ----- a - . ----- --•--- ,
Street - /
as shown on the application for Disposal Works Constr n Permit No��... y Dated>�/.1.'� _/'rS...;................
r ��f Board of Health
-•---••
DATE.- •
../.. ?�_�_:.'..I..... _. fl Ll lJ�nJ sUt_"A�c '���i_ —�D `j C` r ,
FORK 1255 A. M. SULKIN, INC., BOSTON �L—YA L 1 1 �� l �.J C t \ �
9
SOIL LO
1
f N0. 1 FL NO. 1
9 r .ems' l r M
9��
112
r '
4.
r
L A N
5
D, TOP Of FOUNDATION EL.: !�� ` 6
a i�
b I i
Ob i
V E4 'v2 f4 K Cou k_,
IN-El. _�:y •=a �.L �� ;t, EL Ir�0.2 vi4
r >•r ��,,�4-�...
♦ -1-�+-- �D- I • • _it• 10
�_ I♦ �. r s IN.EL.
i
t- —.�
.:• IN.EI IN.EL.
w _ `4tP' rLowrv,,59 .s E 12
` D/B W/ G'" SUMP q `� _ f __� _ F.v. 1
4 LIQUID LEVEL I �� ._ __ ___��_ r .r 14
• Zo 15
PERC T RE
SULTS� TS
PRECAST SEPTIC TANK WITH -
PERC RATE:
CAST IN PLACE INLET AND —� - ---- - — - --- - -�--- Ff-� �, ,A,) -.�.. WITNESSED BY: ^� =
OUTLET T 'S PER TITLE V - Z A!A Z, TA!!L�= a:. ; ,, f _TAR_ LE BOARD OF HEALTH
SIZE : DATE:
f
}
� r
PROFILE FILE OF PROPOSED SEWAGE SYSTEM
0
SYSTEM DESIGNED BY THE TOWN OF REGULATIONS AND
STATE TITLE Y FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE 1/4"= 1 ' 0 •� �� J � 2
J#
��A ffjjj i s i 1
N . B .
1. ALL PIPES SHALL BE SCHEDULE 40 P.V.C. SEWER PIPE
Y
1
2. ALL PIPES SHALL BE SLOPED 1/4 PER FOOT EXCEPT FOR
! Li�,�
THE FIRST 2 FEET OUT OF THE 0 / 8 WHICH SHALL BE LEVEL
��E—Y
3. DESIGN FLOW __________ BEDROOMS AT 110 GALDAY PER BR . __'__. . - __. GAL/DAY {
SEPTIC TANK SIZE . ____ X GAL ,
USE GAL, W/ L,)oa GARBAGE DISPOSAL t7t 4ry
LEACHING SYSTEM : USE 3
x.�° vk oa1
I o F 'ST'n►.3� —
EFFECTIVE AREA : S10E _1_41.+_l+z�i- fs _.__moos},
B 0 T T 0 M AL
TOTAL FLOW --- --_ =__ --- _--35` � i ,a ��-Apo' -t
TOTAL REQ 'D FLOW -t530 X 1.0 W/___a GARBAGE DISPOSAL _ .-' 'Ile
� �
RESERVE FLOW �� - — -
__ 5"�".- � "-� �'i``-- "' �_.� G A l /DAY - _- _ _ ___ __ _ Q,��,,�- �.� y, ` `�' ��
1 Qo,.o
t�4' ,.. E'i CLO` ll tS� S - 1 r .- ,yA .—ice...
r
/ i 4 'CCW/A► t1 tl'r Ic = irs j `
l�k
REFERENCE PLANS : � � . . B_�a.��� J : r. t- � � 3 � TJU
Y> 1
_
I
APPROVED BY :
i
- BQARD OF HEALTH I
DATE > >
PROPERTY OWNER : n _� �- _ __________ _.� _ f SITE AND SEVvAGE V ' AN �
C G' v ` ti
dt: ( , �� � t11A�l C�lAtC LL It �.a►
f3 LOT
_ / f
t -.:x ! ?f _ �� GGy . 1 ; %�,��J fir:�� ( . 4
D A TF 3J
W ILL I L 1E Qt 'R.P'\AIN
5�1N+oit Au E x
ARh!5-CA13L f* , MA 02 G G 13 6 -
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