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L0CA 10 � SEWAGE PERMIT NO.
VILLAGE
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LNST LE 'S NAME i ADOR SS
IUIL0EIt OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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N / .�[�-9`.. FEB....:.••_...6...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_.... .......OF........� •--------------- ----
Appliratiou for Uiipusal Works Tomitrurfivia ranfit
Application is hereby made for a Permit to Construct ( ) or Repai ( ) an Individual Sewage Disposal
Syst at: � �--�
Locati dres or Lot-No.......................................
. ...
Y.aXCff;1t
Address
r ----------•...................
W
Installer Address
�Q
d Type of Building Size Lot_____...�Q�---Sq. feet
aDwelling—No. of Bedrooms._._____._.______ __________Expansion Attic ( Garbage Grinder ( )
p, Other—Type of Building _____ ! No. of persons---------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ._____.._ .._
W Design Flow `K-gallons per person per day. Total daily flow---------- _ ?+ .__.____.P.__ �gallons.
WSeptic Tank—Liquid capacity/67Z.gallo s Le n th__ _ _ _ Width_ _.,1�._ Nameter_____ ______ De th__
x Disposal Trench—Np' °`�� { Total Length____________________ Total leaching area_____._.____�___y____sq. ft.
Seepage Pit No-------------------- Diame�er----1D_.......... Depth below inlet___.........__. Total leaching area,� L�___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.....A,!
Test Pit No. 2_.__--'_..minutes per inch Depth of Test Pit,--.. Depth to ground water______________________ _
P ................................ p ..................
0 h
Description of Soil•----------------40_-r-- -Z--- 'n------�--- - -
x - -
QPat`
v -
W --•-••-•-----------------•-------------••---•-•• 6----�--- ..--_- ----- ...................................................
U Nature of Repairs or Alterations—Answer when applicable---------------------------
_________
-------------------•--------•---••------------••-------------- -•---•-•-•-------• ---------------------•------ ---- --
Agreement:
The undersigned agrees t e afo describe dividt Sewa D posal System in accordance with
the provisions of'T'L:,p ita- ode' u fur gFees not to place the system in
operation until a Certific e o Compliance has b i 41 led"thh',.
oard of I It J
,�f G/d Dd l
Application Approved By.......... .rxj--„ --------------------------
! Date
Application Disapproved for the following reasons:.................................................................................................................
....-•---•----••-----•-•-•-----------•••-•---•-•---•----•---•-----•-----------------------•-•-----------------•-•----•-•------•- --------•--••---•-•--..----------•-•--•-----•--....•-----•-----•-
Date
PermitNo---------------------------------------------------------- Issued_----....................................................
Date
FEE ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-----------
........OF........
-/--- - --- ------------------
Appliratiou for Uhipolqat Works Totutrurtiou thrmit
Application is hereby made for a Permit to Construct or Repai an Individual Sewage Disposal
Syst9a at. ;ep.a,.
............
.. ...... ....... .....................7 ... ... .. ......................................................................
dres
-44
Locati
------------------------------------- ;re or Lot No.
...... ......2,0!:11.164;?
........ ....... ... ...... ....... ------------ . .................................................................................................
Address
e.."tA........_
.......... .........
Installer Address
Type of Building Size Lot____-- ...Sq. feet
U ..........63-------------------Dwelling—No. of Bedrooms---- Expansion Attic Garbage Grinder (
Other—Type of Building ....... No. of persons............................ Showers Cafeteria (
A4Other fixtures ......................................................................................................................................................
Design Flow.5.�2 allons per person Der day. Total daily flow.........._-3. 0...................gallons.
1:4 Septic Tank—L?qTi� pacity/ffM.gallo s Len gth__,� _l__'?Width.4/.�/,0.!Y)iameter-----—----- Depth'.-I......
Disposal Trench—Ni
OaAe"VOW------- Total Length.................... Total leaching area_-_-._.__-- ------sq. ft.
Seepage Pit No-------------------_ Diamerer..... ..... Depth below inlet..... .... Total leaching area.,7 , ..sq. ft.
Z Other Distribution box (1>4. Dosing tank ')
,� . - /
Percolation Test Results Performed by.-_______h 5hh_/.....IA�---(In ---------- - - ------------------------—-----
Test Pit No. 1__J1.-_().minutes per inch Depth of Test Pit......./2...... Depth to ground water......
fT4 Test Pit No. 2..... ._minutes per inch Depth of Test Pit__ ----—_-.:------- Depth to ground water........................
P4 .........�w----------- ........ ................. ...... .----- ----------------..............**-----------
0 je.1:
Description of Soil..................C2..:7.....27...'. ----- .... _7 w----------------
.......... —------------------ .. . .. ..../..... . . .....................
. . .............
.................................................... •........ . .......................
W ........... .. .. 7
U
W ..6---------/-- -----------
-------------------------------------------------/ 3
00 251
U Nature of Repairs or Alterations—Answer when applicable--------------------------- ----------------------------------------------
.............................................................................. . e. q...
..............................................
Agreement:
The undersigned agrees to/ e a f -describe.—.. -- ......./Zdividu ew D' posal System in accordance with
1 1- - ode
�_Li 5 ode u
the provisions of ita r agrees not to place the system in
operation until a Certific to Compliance has b edboth board of-DIY61th.
ned..... .. . .................;, ..... .....
Application Approved By........
Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo--------------------------------------------------------- Issued---------..............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF E LTH A
7.......... .......
................OF........
............*......
e�,age Disposal -.rQ±em wnstviocted or
,
Repa' ed
y ............. ------ .......... ..... .........
--b Installer
at -K--------- ... ............ .......... .....................................................................................................
has been installed in accordance with the provisions of i he State Sanitary Code as described in the
Permit N M_
application for Disposal Works Construction 4? A�_-
V ............ dated___.._._.___.._.............___......._........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..............................9/%VAV .... Inspector..........121,1&0�........................................................
----------------------7.......
THE COMMONWEALTH OF MASSACHUSETTS
---,,-!!—_` -BOARD HEALT
F....... ......... 06"
Ids
N
....... FEE.. ............
........
. .......... ......................................
Permission is hereby granted-------Vkr*.,� 1241V W..............................
to Constr ,--
��e ir ( o� Sewage Disposal System
. .... . . ....at No_ .. ..... ............ -------------------------
-
Street
as shown on the application for Disposal Works Construction.jl�' Vo..................... Dated.._....................................
o
.......................................
Boar Clealth
DATE............... ................. . .......................................
FORD 1255 HOBBS & WARREN. INC., PUBLISHERS
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* LEGEND
CERTIFIED PLO
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I`[NO SPOT ELEVATION Ox0
TING .CONTOUR --- 0 -- -
','R�NISM fiD SPOT ELEVATION
fiNNts"' 0 CONTOUR 0
41
-A0,40VED , BOARD OF HEALTH gA TA W
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HATE AGENT SCALEV 4p� DATE}r, 4
' OR OGE ENGINEERING CO. IN
I CERTIFY THAT THE Rjt0P0, g'
EGl8TERE REGISTERED JOB NO. gUJ�� BUILDING SHOWN ON.:tM1 :
�. . ,: CIVIL LAND CONFORMS TO' THE;
DR.BY t J r
t GI EER SURVEYOR OF 'BARNST BLEB ; MA8> r.
CH. BY I ! k' 4V
` 33. N0. MAIN ST. 712 MAIN ST. 1 ' p"
S0: YARMOUTH, MASS. HYANNIS, MASS. SHEET r OF DATE REG. LA 0
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