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LOCATION SEWAGE PERMIT NO.
VILLAGE
I A LLER'S ME ,- & ADDRESS
DST
R UILDER` OR OWNER
f
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
24V
207 D'
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FRV .... .....:..
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THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
. 1A.1 ........oF::......
8. s il• ................
Appliration for Uiipnstal Morkii Tonstrnriiun thrmit
Application is hereby made for a Permit to Construct (L-f or Repair ( ) an Individual Sewage Disposal
System at:
• •s '"�� �v ! �... .............................................T............------......•--------•--.........----
ocation.Address -.-'---or Lot No.
_...... .... ..........
.... ---------••-•-•-•---•---------------•---------
Owner Address
a •................ 1 vk^)-----•--.........-•--••---.................. .--••--........................_......---------•--••-•----•--------.....------•-•----------•--....
Installer Address
Type of Building Size Lot...... �.._._Sq. feet
Dwelling—No. of Bedrooms.............................._.....__......Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ----------------------------------------------------------------------------------------------------------•---------------••-•------•---------------•-
d
Design Flow................5.�._..._._........__gallons per person per day. Total daily flow.._...............z.............................................gallons.
Septic Tank—Liquid capaclty_lboo_gallons Length.. _`. .. Width. _C_ __ Diameter________________ Depth__S_�...
x Disposal Trench—No..................... Width.................... Total Length.........._......... Total leaching area....................sq. ft.
Seepage Pit No---------/......... Diameter.......Zd.......... Depth below inlet....... ....... Total leaching area...?.—._.7.....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..... .!Y �...,..Ls:. .._. .... ... Date.. ..... c_ y�
-------•---
Test Pit No. I... .__minutes per inch Depth of Test Pit.....1��... epth to ground water.._._ ______________
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____-__-__---_--__.____-
----•-•-•----------------------------------------------------------------------------------------------•--•-•-•-•-•---.....--•---•-----------•-•......_....--
0 Description of Soil------8 ��=- ��------ oa1 4. �... .. SG.I _=Soi ..........��._46 1-1 �'f G�-.....-----
W ---------------------------------------- ---•-•---•------•---••••••-••••-••••...•-••••--------•••••------•-•...••---------------------•--------•-••-••---•••-•-•--••----•-•--•-••-••--•---..........--•-
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 I TITLE 5 of the State Sanitary Co —The undersigned ft r a s not to place the system in
op ion ntil Certificate of Compliance h een issu b 'the and
it e ...... •------• ---- --_ . .-• •. . •-
Date
Application Approved By---•--......•-•--•---•--•. . -•----. {�/.. ....... ........... / D e
Application Disapproved for the following reasons---------------•--------------•--•------...-------------•---•-------------------•---------------•--•-------------
..............................•---------...-•--------•-•-----•...........----•-•--•--..........----•--•-:.__..............-----•....-------•••---•---------------------------------•-•-••-•••-•---•------
Date
PermitNo......................................................... Issued_.......................................................
Date
---_.__--------
y.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Ui"os ai Works Tonitrurtion rrutit.
Application is hereby made for a Permit to Construct (t.-I or Repair ( ) an Individual'Sewage Disposal
System at
.....sal'.a?�•" ......�!.ns�G.....e �....... �//..r....-is .----•------------------------•--.._��'T .....--�-----------•--•------......-------•---
ocation-Address or Lot No.
�!�/ _ .. •- -----------•----------------- - -.._...........
Owner Address
_':,T"`= . �1(V( ............................................ ..............--------..........----------•--••---•--_.._...-----•-•----------•-•-----............
-----• .
Installer Address
UType of Building Size Lot.._ZL,c.. '�`......Sq. feet -�
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther Other—Type of Building ............................ No. of persons.....___._...........__._.._ Showers ( ) — Cafeteria fixtures .
W Design Flow................53..................._..gallons per person per day. Total daily flow.............................................ZU!..........•.-..gallons.
WSeptic Tank—Liquidcapacity.lb�9..gallons Length._ G."... Width_��..�_.__.. Diameter________________ Depth..:5_.�.._.
x Disposal Trench—No.....................Width.................... Length.................... Total leaching area--------------------sq. ft.
Seepage-Pit No......... ---------- Diameter.._...Ze_._...... Depth below inlet......!?-.......... Total leaching area..!?�4_7......sq. ft.
z Other Distribution box ( ) Dosing tank ( )
`" Percolation Test Results Performed by..._G�!�`l `��._.__L'.` `u �_.-_..... Date..FE .... j� s�.�
Test Pit No. 1--- __Z._._minutes per inch Depth of Test Pit----- .... Depth to ground water...."T"...............
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_-----__-_-_-_-----_-__
�+ .--•----------••••-... --- ---------
D Description of Soil----�fir- ��.....��'%�D _/ -Sup:S"�[. Z¢��- �� ------------ °'
W
-------------------------------------------------------------------------------------•--•--------•----•-----------------------------------------------------------------------------•--•-----•--_.....
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 TITLE 5 of the State Sanitary C d —The undersigned fort r es not to place the system in
operation until a Certificate of Compliance ha een iss b the "oar f h h
ned..� •--• . .-• --- ... ,r
/_----•-------- --------- ate--•--...------
`"a"e.� � ` � f � Date
Application Approved By .._......`.... ;_ .._.._.. , '~
. ✓ .,r _.k__.._.__... e......... ............ ..._.._._J./...G_.
Application Disapproved for the following reasons-............................................---------------------------.....................................
----------------•--..........-•-------------•--...----•----••--------•--•-•-•-----•••........•------••••---....--•---------------•----- ------------•-••----------••-•----------••-----••-•---••--------
Date
PermitNo...................................................---- Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS M -
BOARD OF HEALTH
.............'T .........oF.....
sT�-�3....E.............................
At
Luntifiratr of ToutpliFattrr
THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed (L,.-'or Repaired ( )
by . ................•-•-------•------•---•-..._-------•_..
�• 1a�taller
at* •---------•-- ' t `
has been installed in accordance with the provisions oTTTT „r r The State SanttaT-y,&e,as described in the
application for Disposal Works Construction Permit No_.... dated_-------���.�-� ......._...
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONS RUED AS A GUARANI E THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................. ............ Inspector.
...................
THE COMMONWEALTH OF MASSACHU TTS
BOARD OF HEALTH
:.
No........... FEE_.....................
Dispos al orks;.ZlInoirnr#ion rrutii
Permission is he��eby granted.......V�?ju.n.�b...........I...............................................................................................
'
to Construct (&, or'�2ep it ( ) an.,IndiviidduaI S wage Disposal System
atNo. `� j� ---..� ?. .-------------------------------------------•------------------- ----- ---............
rc.
as shown on the application for disposal Works Construction Pe t�"1 et Vo` —................ ate .._____ � / -_--.-._--
DATE. — Z J v ......_________________________________ Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
f.a SNIT / of 2 SNITS
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An s� /ANN/S /y.95
LOCATION . . . . . . . . ... . ..
SCALE . 30 . . . DATE ?2iG
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PLAN REFERENCE . . 3E- ni� lo: "`�
deaC A: 4,q-A/,D �ourz.T
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No. 26,C,J
d .. . .CERTIFY THAT THE .. ..
s,;.. SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
� n AS SHOWN HEREON AND THAT IT CONFORMS TO THE
II �� SETBACK REQUIREMENTS OF THE TOWN OF
WHEN CONSTRUCTED.
DATE . . . . . . . . . . . .
�//GL/•A�9 F. SW/FT /�E ,T/�'N� REGISTERED LAND SURVEYOR
;38.0 O
TOP OF FOUNDATION
CONCRETE COVER
TCONCRETE COVERS
¢¢s a 4"CAST IRON II2"MAX. r
OR SCHEDULE 40 � � 12"MAX.
P.V.C. PIPE 4 SCHEDULE 40 P.V.C.(ONLY)
PITCH 1/4"PER.FT PIPE.- MIN. LEACH
1� PITCH 1/4"PER.FT. PIT PRECAST
`—INVERT _ Q ••;�:: LEACHING
''e EL••33,*3..• INVERT INVERT : . ( PIT OR
a', SEPTIC TANK DIST.
e INVERT EL.. 33:!7. . BOX EL3z,83 j= ��I EQUIV.
e EL..33, ¢ /000 GAL. INVJ3ToQ INVERT �' v°- 'J' :;i: 3/4"TO II/2'
� EL....... EL3z.Sp o �: WASHED
e Ila
w STONE
O EZ.u..'t0 •.i
/G/---► —B'DIA.
�.;,• , /o' DIA. r�D
PROR LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
�- ¢/o Z_
SOIL LOG WITNESSED BY :
DATE . z/./08� TIME. 9, 30 .�'? TfM?G3 �. . �^! ^! • BOARD OF HEALTH
TEST HOLE I TEST HOLE 2
3¢. So ENGINEER
ELEV. .
ELEV. .. .. . . . . . .
2¢" see so, DESIGN DATA :
EL.3Z..f
NUMBER OF BEDROOMS
do" ez 27 ro TOTAL ESTIMATED FLOW . . 2 20 . . GALLONS/DAY
BOTTOM LEACHING AREA 78•So SQ.FT. /PIT/C,P.D.
SIDE LEACHING AREA �PB,So SQ.FT./ PIT/47/C_eP_
L°oA7LSE;� GARBAGE DISPOSAL .!✓4 � (50% AREA INCREASE)
.SAS p '
TOTAL LEACHING AREA . SQ.FT
�•ZZ,�o
PERCOLATION RATE /'"c* MIN/INCH
LEACHING AREA PER PERCOLATION RATE . .. SQ.FT/C,P.D
Y?7WATER ENCOUNTERED -- _ --
NUMBER OF LEACHING -PITS T!t/17W
APPROVED BOARD OF HEALTH '���
DATE . . . . . . .
AGENT OR INSPECTOR
44
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PETITIONER : W '•
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