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ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. J.P.Macomber Jr. SEPTIC TANK CAPACITY 15 0 0 + Box LEACHING FACII.ITY: (type) 5-5 0 0 ' s (size) 3500 gallons NO.OF BEDROOMS 6 BUILDER OR OWNER Gary Gustafson Inspection PERMIT DATE: 4/3 0/0 3 COMPLIANCE DATE: 4/3 0/0 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fe of leapt ng fIci '0 Feet Furnished �, p iiy v jigsf �N s h 1. 0 CAT I" S E VILLAGE cf �� INST A LLER'S /NAME i ADD d U I L D E R 0 OWNER DATE PERMIT ISSUED- 7-- � ' DATE COMPLIANCE ISSUEDJ�'—�(� 9 E-? vy:? L'0 C AT 10N v� �` "� � SEWAGE PERMIT NO. VILLAGE I N S T A LLER'S � NAME i ADDRESS_ S!U 1 L D E R OR OWN ER qi n() r' ci DATE PERMIT ISSUED DATE COMPLIANCE ISSUED L i r ! c514 i 1 Al l No y G S -- �:._ ,� Fxs...61.6f a.. THE COMMONWEALTH OF MASSACHUSETTS �s BOARD OF HEALTH ---.....0 F......j.*i. .474 e............................ ApVtiratiun for 11iupuual Workii Tatuitrnrtiun thrutit Application is hereby made for a Permit to Construct ( ) or Repair ( l5'-an Individual Sewage Disposal System at: /I ell Location� - ddress 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 ( ) Otherfixtures ------------------------------------•--......---------...------------------------------------------------...........-----------...----•.........._.... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity..._.._..._.gallons Length................ Width................ Diameter---------------- 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................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -- -------------- Descriptionof Soil...---- ------'..------. A�J.`. -- ---•--------------------------•---------------------•--•---•------------•----------.........---- x c, x ---------------------------------------------------------------------------------------•-------------------------- U Nature of Repairs or Alterations—Answer when applicable-___ - = W------------------------------------------- ------------- -•----------------------------------------••----------------------------•--•--•-----........---------------••-------------------------•----------------------------------------------------------•-•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'ILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued the oard of health. D ApplicationApproved By------------ ----- ----•---------...-----•••....-----•-•------•--.........................---_.. ------ -- y Date Application Disapproved for e f owing reasons---- ----------------------------•----------------------------•--------------•--•--------._...--------.....------ -•......•-•-------------------------------------------------------------••------•--..........-----....._..--------------•----------------------------------------------------------------------------•-•- Date PermitNo......................................................... Issued...--•-------- Date S r No........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. Appliratiou for Disposal Works Tonstrurtiun Virintit, Application is hereby made for a Permit to Construct ( ) or Repair (k')�an Individual Sewage Disposal System at Location-Address or Lot No. ; �......_......... t. , `-------------------------------------- ..........--...................................................................................... ownec Address W Installer Address Type of Building Size Lot............................Sq. feet 1•—� Dwelling o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons...........:................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------•------------...------------.---------.--..-----------------------•---. ----------------- W Design Flow............................................gallons per person per day. Total daily flow..........._................................gallons. Ix Septic Tank—Liquid capacity............gallons Length............... Width................ Diameter................ Depth................ 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I...........:....minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0s4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ............ - ••... .................................................................................. Descriptionof Soil------ nr� A-- rl -----------------------------------------------------------------------------------•------------- ..............................................------------------------------------------------------------•---------------------------......---_....-----------•-•--•---•-•---------•-•-------------. W ------------------------------------------------------------------------------------------------------------------------•• •-• -------------•---------------------------------------- ------------------- V Nature of Repairs or Alterations—Answer when applicable___ ,_ ,_,e! .............................................._......__....... --------•--•------------------------••---------------------•--------•---------------.....------......--------------------------------------------------•--------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI:L 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�y/theoard of health. Al Date----•--•------ Application Approved By........................ -----------•----•---•-•-----•-••---•-•-•-----------....--•-•------ -, Date Application Disapproved for the following reasons:---------•------------------•-------------------...-----------------•---------•-----------••--•-----•-••--•-•-- --------------------------------------------•------•----•-------••----•--••------•-......-----•--•------•-------------•----------------------------•----------------------------•-------•-------------- Date PermitNo......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trrtifiratr of Toutpliaurr T�H,IS JS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( . by--- �...... ' r2_ , .... ✓ ------.... ..............•---••-•--------------..............----........--•------------- ,. t has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM 1IYII,L F Cy ION SATISFACTORY. DATE--.7-..L / Inspector... _ THE COMMONWEALTH OF MASSACHUSETTS ,�. BOARD, OF HEALTH ......d. '...........OF.....e .......... . No..................... Disposal Morks •Tonstrudion Prrutit Permission,is hereby granted......��._ _____ ',tc �`: ' :____.___y._..[.N y' 'y `._ _______ . ....... ................. to Construct ( ' ) or Repairs an Individual Sewage DisposalSystem atNo..........................-----••---••------•----•-------------------•=--•---....------•---•-•----_-------------------- ------------•----••------------------•--...-•-------•---••••......... Street as shown on the application for Disposal Works Construction Permit No..................... Dated............................................ -----------.......................................................................................... Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON