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L O CATION S.E W A G E PERMIT NO.
VILLAGE`� JJ
� INSTA LLER'S NAME & ADDRESS
B U I L D E R OR OWN ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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VTHE COMMONWEALTH OF MASSACHUSETTS
— /-,, , -- BOAR F � TH
....
......OF........ .. .. A........-..�
Apli iratiun for Uhij tt1 rk Tonotrnrtinn ramit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at: _ /'
...............•--------- .. .. --.........----...... . ............................•-----••-•-........7..............................................
Loc n-Address or Lot No.
.,� ..... .0... ........................••-----•--.........--•---............------.....----•--•-••----•-------
Owner _Address
-•-•. .....................a ---.---.... ..... - �� ..:................................ ........................ = ` ...-._.
Installer Address
QType of Building Size Lot..-__ ,._. 6. ----Sq. feet
U Dwelling—No. of Bedrooms____________________ Expansion Attic (P76 Garbage Grinder 1�6
--- —
a Other—Type of Building ...._.._1 ............: No. of persons.......... .............. Showers ( Cafeteria ( )
Q Other fix
t------ - ----------------•----•-•--------------------------- ----------------.......----..............-•-•----
W Design Flow.......... ........_--gallons per person per day.. Total daily flow............. ....................gallon`
WSeptic Tank—Liquid capacity../4!2/2).gallons Length-...,//.._.. Width.6.......... Diameter................ De.th.....-6.......
x Disposal Trench—No......,� _. Width.................... Total Length.................... Total leaching area.�66.6.....sq. ft.
Seepage Pit No-...--------- P ..... a ..................sq. ft.
�iameter............... Depth below >nlet..._........... Total leaching area .__._____
Z Other Distribution box ( Dosing tank ( )
'-' Percolation Test Results Performed by....... ._ ,•...._ Date............
..Z..�
Test Pit No. 1..��r. -...minutes per inch Depth of es Pit........ ....... Depth to ground water..--., � .-..
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
............. _....... y� ...............--------------------------------------------------------------------
O Description of Soil........6, �Y r..... , ' __z�: 11`t-�_.. `
x
U ............................... � . -•-•.L.4--••-•--•- ... -------:n.............................................................................
--------------
U 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 iITIE� 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... ........
Date
Application Approved By................. ......
ate
Application Disapproved for the following reasons----------------------•-----..........--••---•---•---•--•------•-------------••-•-------------••-•-••-------•---
............................•-•-••---.................-•--•-••-•---•••-•-•--••--•-•-........•••-••--......•-•-••-•-•-•......•-•---•--•--••-•-•-----•----•••---•--•-•---•• •••••--•--•----..........-••--
Date
Permit No........�3s�.. _.� . ... -. Issued....... `3 $..... -----
Date
-- ----------'<'-5-------------- --
a
No......................... y. FEs..............................
ATHE COMMONWEALTH OF MASSACHUSETTS
\,B0AR® F` LTH
...........
T .. ;..
........ off'........ ...,�f�1 ..,�4-----=----------------
Applirttfion for Bhip sttl Nark Clvtwlrurtiutt Permit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at:
4� C
Location-Address
r' ,.. .........or Lot No.. ..........................................
[
Ownez _J Address
IQ
... .......�... --•-----
Installer Address
Type of Building Size Lot.. .lam____���.�+----Sq. feet
Dwelling—No. of Bedrooms.................-._._.`..------------------Expansion Attic (yj�) Garbage Grinder (✓fc)
Pk Other—Type of Building ________ ......No. of persons....................... Showers Cafeteria ( )
dOther fixtures ------------ f!j`- --------------•------.............--------------------------------------------._.....-•-•-----....---••-------..............
W Design Flow........................................gallons per person per day. Total daily flow.........s. ....................gallonss.
WSeptic Tank—Liquid capacity._ /Vgallons Length..../1 ..... Width.:l� ........__ Diameter................ Depth......4.......
x Disposal Trench—No. ....../9.` .. Width.................... Total Length.................... Total leaching area.2Tl u!:-----sq. ft.
Seepage Pit No------------- ------- tameter........._._._______ Depth below inlet........__.......... Total leaching area..................sq. ft.
z Other Distribution box (1/� Dosing tank ( )
Percolation Test Results Performed by....... ... ._ ......?._�-t -�A_---.---- Date.............- 1�. / r • 3
W
a Test Pit No. 1..G ^..minutes per inch Depth of Test Pit....... Depth to ground water.....,j'� �:: _._. `
r4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P: ----••-•--• K ................................................... ......................................................... ..............
Description of Soil------.. ;/ ' r ��,...Z.... 3 .....
x ---------•---
W
----------------------------------------------------------------------------------------------------------•-•--------------•---...---------•••-----•------•--------•-----••-------------•--•----•------
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 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.
Signed 1,�4i... Nrs.._.Di^�7i�r (,-- , r-A,.(-•-.-•-•- ---
-----------
^ Date �
Application Approved BY --------....�. � .... .................. ------� '� X.r7...._.
ate
Application Disapproved for the following reasons-----------------------------•-------•------------------•----•--------------•-•-•--------.....--•-----.....••....
...........................................----••-•---------.....-•-----•------•---•--.....--•-----------------------•...-•--••-----•----------...•---•-•-------------•--•......---....---•------.--••-
Date
Permit No............g � �e -------••-------. Issued......- � .:'.04_ ....:
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH _
r ,..... .... ....................
Trrtif iratr of Tomplitturr
THIS S
y......_...;.. .. .....
TO ERTIPY at the Individual Sewage Disposal System constructed or Repaired ( )
b / T�.......:...... Installer .........................-........
at. '" ,� .k lit/. ` fl�a�!r.r,� f�''r .......:
�... .......................... ... „------ ------
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....... _ !Ste"....... dated_....`�' _.. ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT`BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM JILL FUNCTION SATISFACTORY.
DATE. ..... • ............. Inspector--.-.t -----
._... --�e{A41Vk
THE COMMONWEALTH OF MASSACHUSETTS
�- BOARD OF HEALTH
-: .........O F.....d* iC'. / } r•
v? FEE....f :...............
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Permissionis h eby granted (C .f:---------------------------•-•-----..........-----••---•-•-------......----....................
to Construct ( or Repair ( ) an Individual Sewage Disposal S�'stem
at No......... --•----••---� i=>!-�i-cs{ •� _:> .._------------------•------•-------------( M..
....3 .........................................
Street
as shown on the application fo Disposal Works Construction Permit No.................. . at ..........................................
= . . . -- ------------------------------•--...-----......
rd of Health
DATE.... .. . -•.... 3--.--
FORM 12$ ' A. M. SUL.KIN. INC.. BOSTON
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LEGEND � CERTIFIED. PLOT PLAN
EXISTING SPOT ELEVATION OxO f,, . n
EXISTING CONTOUR ——— 0 --
FINISHED SPOT ELEVATION
FINISHED CONTOUR --- 0 ------ r`
APPROVED BOARD OF HEALTH ,,' ., , IN 'F
DATE AGENT ` , SCALES (� — 4o , DATE , 9z
LOREDGE ENGINEERING Ca ING CU NT I CERTIFY• THAT THE PROP09E0.
EGISTERE REOISTERED, rtf JQN;NO., . ,�,�? BUILDING SHOWN ON THIS PLAN
CIVIL LAND i z CONFORMS TO THE ZONING '-LAWS
ENGIN ER .DR� Y�� �*— OF.8ARN9TI119L , M SS.
712 M At N STREET
NYA NN I S, MASS.
r ' SHEET. OF ; — DATE RE�. LAND SURVEYOR
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