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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
�CrZ�lZ........:........-0F.....
ApphrFation for Ilh4paii al Works Tutwunrtinn Fermi#
Application is hereby made for a Permit to Construct (X) or Repair. ( ) an Individual Sewage Disposal
S stem at*
qp/ ...... Azad......T..+V. /..�............�.� i�.......... ............•_____••___..._.._... ..�•i-------•---•---.-..-...-•---.-------------------------•-
Locati -Add.-.. re or Lot No.
....._.... !¢/. .�t .�. .l. - ........ .............................. n'' lf---------------------•---------------•--..........---
!/ ner Address
..... c.. �...._. �d.lS� .... -•--•----.......-• ............................................................
Installer Address
S Type of Building Size Lot---- _, ....... q. feet
►, Dwelling—No. of Bedrooms........-..................._...._.....Expansion Attic (A/D) Garbage Grinder (IJO)
Other—Type of Building a yp ng _�ao___.�....... No. of persons...................... Shower s/(� — Cafeteria (,lJv)
dOther fixtures -------------------------------------------------••• -------- •--------------------
W Design Flow........1 .....�-��_---......gallons per person per day. Total daily flow..........�_� .....................gallons.
9 Septic Tank—Liquid capaciitylJ.O."Dgallons Length----16....... Width.....&------- Diameter-----6,-...... Depth...,F.........
Disposal Trench—No. ... Width.................... Total Length.................... Total leaching area..1!_/......sq. ft.
Seepage Pit No...kJ.Q `V'_. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (}() Dosing to
Percolation Test Results Performed by-__.tom 41'f6?C---�✓?�t`__ C_... Date.....�Q ._ 1...........
,.a Test Pit No. 1---4.sl----minutes per inch Depth of Test Pit....1e1.......... D pth to ground water-__-, _.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ------...........................r----------------------------••--••---------------------------------•--------------•---------------•-------------•------.--
O Description of Soil...... !.. d=;lry
a.5_`L)Azw7.6.•--••--••-•-----•-•-----••-•-------•-•------•••-••-•--••-•••••--•-•--•---•......................
v -•-•-------------•--------•------- .........f'Y1 °�
x -------------- ----------------�=«. ����.....s;1XI&..._.............................................................................---------------------------...
V Nature of Repairs or Alterations—Answer when applicable_____________________________•-____---..-.____-____-------__-_----_-_-___-.-_---------------_-.
--------•--------------------------------•----...-•--------------------•-......----•-------•--•-•-•-------...-•-------------------------------•--------•-----------------------------------------......
Agreement:
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 undersigned further agrees not to place the system in
operat' njul�aCertifica Compliance has been issued by the board of health.
—� Signed-/V .' . -1 ! t - C•---•-• .....l ••••-�..��J
Application Approved BY- r" ".=-� C�_......r1'z'` ........................... a. S._.._..._
I/ ate
Application Disapproved for the following reasons----------------•----•-------•--------------------------•-----------------------•------------------..........----
----•-......•--••---••-•--•--•----------------••-----••---•-•....._........--------•-•-•--...•-------•-...-•-•--•••--•-•------•---------••--••-----•--•---------••----•-•-----•---------•--•••--------•--
Date
PermitNo....................................................... Issued........................................................
Date
............._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
( 1,�j-... OF.... ."'..............................................
Appliratinn for Disposal Works Tonstrurtinn Prrnti#
Application is hereby made for a Permit to Construct ,( ) or Repair ( ) an Individual Sewage Disposal
System at
.... .....!L:..„ --T-• ........................................................
fJ ...
Location-Add ss or Lot No.
` --j) e 1P ?ria Y
•-----••- - ----- ' -•------- ----------_------- .
t {tea Address ..........
� � -------------•-.....------•---•...._ ...........--------...-----� :; .....................................................
� Installer Address
UType of Building Size Lot.__,&.,;M;�__._....Sq. feet
1•-1 Dwelling-No. of Bedrooms..........,��................................Expansion Attic (VO) Garbage Grinder ()0)
a Other—Type of Building _I
p �. r,................... Showe — Cafeteria (G1�)
a yp _ �C!_�_. '__?___..... No. of ersons.__...
d Other fixtures -----------••-----------•-----------•---•---------•--
W Design Flow......../, _•--.--.....�.a'�--.._.__gallons per person per day. Total daily flow.__.....__ .0................. _gallons.
--
WSeptic Tank—Liquid capacity/ _gallons Length---/t)........ Width----6........ Diameter----f_........ Depth.. _._.._....
Disposal Trench—No.A'. ��:.._.. Width.................... Total Length............._...... Total.leaching area- te, _. s ft.
x g �------- q•
Seepage Pit No..J,!4VV�_.. Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (X )' Dosing tank ( )
Percolation Test Results Performed b ._ c ./MO&�. - .. t�:g r.i�_ ..__ Date----./q
...p p pth to ground water '40-6k :
lee.V---------
Test Pit No. l...e�:,�:_...mmutes per mch Depth of Test Pit _.______.._
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..................
..................................A.................................................................-.....-----•........-----------••-----------------.....--
O Description of Soil.._.11.`. .. ..40.etw. ?C
Aj
UNature of Repairs or Alterations—Answer when applicable.....................:_____...._____.....___........________._...............__................
----------------------------•---------------------------•--•------••--------•-•-----........-----••-----------------------------------------------------------------------------------.................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 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.
ApplicationApproved BY...............................................................................-------••-------- --•--•--...............................
Date
Application Disapproved for the following reasons-------------------------- ....................:._...---•---------=---------------•-•------••-•-------•----
----------------------••-----••-•---------•-•--•••-------••--------•--••--------•---------•-----...-----------------•-••-•-•----------------•------....................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ham.. ....... .......,OF.... ?1 ":.:.:....................................
(9rdifirtttr of ToutpliFanrr .
THIS IS T CERTIFY at the Individual Sewage Disposal System constructed ( )' or Repaired ( )
by .::.ylf f r".... ._��..
s .. Installer ............................................................
r
at f! t Clef_ .__ ; ��------------- .� .....'r ...
has been installed idaccordance with the provisions of TITLE 5 of TXie 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 GU ANTES THAT THE
SYSTEM WILL FU CTIO SATISFACTORY. s
DATE................. Inspector.. -\ -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Zca
cs / :..............OF..... Zts. : 9. ......................---•••--•--.........
No ...................... FEE........................
Disposal Works Tan trnrti.an rrntit
,r
Permission is hereby granted-...... --•-------------------•---•------....-----------------•--...--•--•........................
to Construct (A ) or Repair ( ) an Individual Sewag�e Disposal System
-
at No.- V--------
'l' cf
' Street a"� � � -- ! �����'........
as shown on the application for Disposal Works Construction-Pe mid--NNo..................... Dated..........................................
------------------------•--•---•-•-•------ --•-------------.............................................
DATE. /CC ——/ S ___ Board of Health
FORM 1255 A. M. SULKIN, INC.. BOSTON '�„
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ING SPOT. ELEVATION Oa0 'EL RED
!'�'I•:IN CONTOUR �- 0 _ -- CERTIFIED PLOT PLAN
�'� I4N.jZ ;,. SP®T ELEVATION
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NOTE :The location of any existing undergioun sewerage,
• wel is ,.or other;,utilities shown on this plan is approx- IN �.
G4r Q4fijdte-_onl as determined from records and/'or verbal ® e t r
. t nfoxmat 6' Th 4'contractor isresponsible 'for the `� '�'A j '
f�uer��f cat on of the existing locations in' the field. 3CA�E� "_ _t DATE I /2 8'I,
' RED Of ENGINEERING CO IM CLIENT.:,
_ ------------ I CERTIFY THAT THE PROPOSE D
g t EC3ISTERE REGISTERS® SOB NO. d?4029F' BUILDING SHOWN ON THIS - PLAN ' '
�Y(St.
CIVIL LAND CONFORMS TO THE ZONINGS LAWS� �� EN® NEER d1RV ------^-�-- OF `IAI$NSTAF3L E MASS. y
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?IU MAIN STREET, "
CH. BY
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HYANN I S IMA3S. /2C,PE
SHEET OF A KEG.. LAND SURVEYOR.
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. � - CERTIFIED PLOT PLAN
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IN
-1367
DATE
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► C,v��B��.S" . .,
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[" CERTIFY THAT THE
NTT.,,. ... :._,. SNOWW ON THIS PLAN 13 LOCAT94
dr t I. -1.tfir"�i6� 1� ,.-. / ,f ON. THE GROUND AS INDICATED
CIVIL LAN
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EId�lNEIEI� S!I&BYEY®R f CONFORMS TO THE ZONING LA 4 f'
4 fY RIV�TABL.E, NABS
T12' AAAM `STREET;' GIIti, Yo .. {—�—
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HYA►.NtRIS MdASS :" I NE 1'„ �� .. AT'le REG: LANO SUI�YEYOA
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