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LOCATION SEWAGE PERMIT NO.
VILLAGE
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I NSTA ER`S MNA�/Fi . ADDRESS
BUILDER OR OWNER
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DATE PERMIT ISSUED
DAT E C0M;PLL'VANCE ISSUED
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CX
Y.S:-
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No....... .. ..1� _' _ Fizs..I o............
THE COMMONWEALTH.OF MASSACHUSETTS
BOARD F HF TH
lojt/l .................OF.....
J�14� Appliration for Bwvviial fur�) or
Construction erutii
Application is hereby made for a Permit to Construct Repair ( ) an Individual Sewage Disposal
System at
...... r . -------------- --------------- _5� . tio . ...__
... ...
Loratio - ddress t No.
ev.
"7"" O Addres f /
a �J = .._ ............ .................... ��aa' Gt..:. "V-4 (.�/...-•----
Installer A ress P D
Type of Building ize Lot.......... .....Sq. fee
Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( t/ Garbage Grinder (/ U
N Other—Type of Building _.._.._... No. of ersons____________________________ Showers
Q' � - ----•--•--•-•--------------------------------P ( ) — Cafeteria ( )
dOther fixtur ---....----•-•-----•------•-------•------------ ------ ---•••-•---------•••--••-•••----
Desi n Flow__________.s. ..............gallons per person per day. Total daily flow________________ gallons.
W g --------.. - g P P P Y• Y �-��--------------
WSeptic Tank—Liquid'capacity._f.tvu__gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No...../------------ Diameter../_U__........... Depth below inlet...... ........... Total leaching area__4;L ...sq. ft.
z Other Distribution box ( ) Dosing tank ( /)
�" Percolation Test Results . Performed by.._ �1!'--1�. �'�_.'.�� Date........................................
/`"" --
Test Pit No. 1..... minutes per inch Depth of Te Pit
_..... Z_______ Depth to ground water.../U0 �4/_.
fr Test Pit No. 2................minutes per inch Depth of Test .._....__...._______ Depth to ground water........................
... J --------•-... "---------------- ---•----"I'll"------------
�
Description of Soil----••--• --�--•--_ _ 19
W ..............� . ' - -
!-l.Z _....__ yl'�S -----••-•------•-•----------_----
x ...--•--•----------------------•-------•--•-•-.....-•-•--•--------------------•-------••----•--;•-••----•------------------------------•---•-----•--•-----------••-•-•-•-------------•---•...._-•-------
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 Code— The undersigned further agree of to place the system in
operation until a Certificate of Compliance has ben'issued b the bo d of h
•, ../ _
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9
Signed (lf ------••---- ,e
Date
Application Approved By___________•__...4 '---- 3_-�!_-�,!_____
.--•-----...----••.................. ............... Date
Application Disapproved for the following reasons____________________________________________________
----••........................••--•--••-....-•-----------•-...-----------•-•-------------..:•-------•••....---------••-•.._..---------•-----------•--------•-----------•-••--------•------------•-__-•---
Date
PermitNo......................................................... Issued_.......................................................
Date
No.......4 .......
�� Fss..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD,OF HEALTH
............... .......................OF....
.....:..:.::....:..::.............. ::......
Aindiratiun for Disposal IVnr Tonutrurtion Permit
Application is hereby made for a Permit to Construct ` ) or Repair ( ) an Individual Sewage Disposal
System at:
................_........._...................................................................... -•----•••----•--......_.......•-•-------•••..........--•••••-•••-••-••••••••-•.........=--:....__.
Location-Address or Lot No.
........................................................ .......... :.:.__._.:.... ............
w Owner Address` li.
Installer Address
Type of Building - Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
a Other a —Type of Building .................-.......... No. of persons............................ Showers
( ) — Cafeteria ( )
Other -----------------•----
w Design Flow..........- ..:.........................gallons per person per day. Total daily flow..............3. ......________._gallons.
WSeptic Tank—Liquid'capacity.l0.1-u...gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width ....... Total Length.........._r...... Total leaching area....................sq. ft.
3 Seepage Pit No..../............ Diameter. 4............. Depth below inlet....-<a_............ Total leaching area.. ....sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Resultgp.-7 Performed by. --_ ._ %..................................° - •--...... Date........................................
Test Pit No. 1....G..... _.minutes per inch Depth of Test Pit...._�_z _.. Depth to ground water..&a?!4�''_ .
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x •• -
o 0_ �
Descriptionof Soil-••••-•--••-_-•--- l" ----------------••....-•-••-•--•-•- -•-••••-•......_._._......__.
Ile
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 TITLZ 5 of the State Sanitary Code— The undersigned further:a4grenot to place the system in
operation until a Certificate of Compliance has en issued the b o rd of lie
h.
gl
Si ned- / / ,�9 ........... ��
Date
Application Approved By-•-••---•-••-�' ..::•��// - .�
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------•-•-•••-•-••-••-•-•-•-•-•----•--
-----------•---•••••..........•••..............••--•••-••-•--•----•....-------••-.....-------••---•--•---.•-•--••••-•--•--•-•••••....-----------••--••••-----••••••••-•••--•••-•-••--•••••••-•-....------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
?` BOARD-OF HEALTH
,/
A�,x-
OF.......... .. ..................................................................
Tnrtif irate of ToutpliFaurr
THIS IS O CERTIFY, That the Individual Sewage Disposal System constructed f/�) or Repaired ( )
t...........�______________ -_____-__--•--------------•------_-.:..
by................... �,%;-�-�af?.� Insyfuer
has been installed in accordance with the provisions of T F 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No &/ ..Z�3.................. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM! WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�iu�us� ur�u �unu#riun �.rruti#
Permission is,. ereby granted--••••
to Construct ( or Repair ( ) an Individu Sewage Disposal System
at No.••••••...........;� ......•... -
Street
as shown on the application for Disposal Works Construction Permit No..................... Ddted..........................................
Board of Health
DATE ._ � -••••--•--••••.
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS `
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LEGEND ;, r :
' EXISTING SPOT ELEVATION Ox0 �H o� CERTIFIED PLOT P�Aj M
EXISTING CONTOUR --- p M�ssq e �'. �'' ''.` t► :
FIOtt9HED SPOT ELEVATION, o� ROBERT;
FINISHED CONTOUR 0 f P.
u 13UNIKIS Y t a r'J
.a.yt•,:it _. ,.. . (�I t I I� Y �,CY ty d�.,'�TY
/APPROVED -.BOARD OF HEALT No•22162TAILS
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z DATE AGENT �._ SCALE, / ~- AG DATE:
LOREDGE_ENGINEERING CO. IN CLIENT ����
I CERTIFY THAT THE
E dISTERE REGISTERED JOB N0. G° BUILD1.M6 SHOWN ON 1'H
CIVIL LAND !'� CONFORMS TO THE . ZDi. : 4
ENGINEER SURVEYOR DR. OF BARNS ® E, ,
712 MAIN ST. CH. BY:
f NYANNiS, MASS. �•'^ •x
SHEETJ- OF DATE REG. L�d►N-0 f
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LEf#CN" lvG M:nR� TaAsV LorV
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COME
N `: ". er/E'A0�7 f�-24 Q/AMETER. CoNC'R�T�
{ M S/,IALL ':BE ;�9R.OU6flT TO.GIr{A"vE;�,AN:EXTRA _t
r
4"PVC pip_
CONCRETE N l/EAYY .CA.S? IRON GDv�R""S/��4LL DE uSw I
CDYERS MIN. P/TC. /F!N ,DR/VEN<A,Y
-2 MIN.•.
03tAoe CU VER" CLEAN SANG i
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i L/Qt//D LEVEL z
e 2 I-AYEI?
-IRON P/PE GAL. o •a o 1 • • • -• "• • • 1 l d oo� �/ASHFD 57t7NE
P/TtN D/ST.
V a • • • • • 1 • o a
Q"Perm yr. SEPTIC TANK a 1 • •a
BoX o • � ® • • • • • 1 A a •
• va o • • •EFFECT/VE 1 • + 314 a V2
e ° 1 • • DEPTH • • ' o WASHED STONE
•,.:.::o; e e,'e 1 • • • • • • t ► o p o P/PECA5 T SEEPAGE
e u. • 1 • • • • • •.o"1 D ••P P/7 OR EQU/V.
!NVeRT ELEVAT/OHS o p a
INVERT AT QU/LD/NG `t O FT. 6 D/AM. fi
INLET SEPTIC TA/VK �`' F ,T _L�1 FT. PIAM• C SEE TABUL.4TJON�
�
OUTLET SEPTIC TANK 9S' 'FT.
INLET D/STR/BUT/ON BOX 9s'G FT. SECT/ON OF' GROuNO Itr�ITER TABLE
OC/TLETD/STR/B/lT/ON BOX FT
/NLE7*LEACH/NG PIT 7, 0 FT SEN/�4GE O/SPOSAL SYSTEM TABl1LAT/DN
LEACH//V6 p/T v//tiENs/oJv A
DES/G/v CRITERIA SCALE /4 ' ,p/AIE-NS/ON a L' FT.
D/
NUMBER OF BEDROOMS MENS/ON C— FT./ � +�
G/1RBAGED/5P05AL UNIT_r SOIL LOG SOIL TEST
TCTA4 E.TT/MATED FL0AV G GAL.1,DAY SOI L TEST+ #I SOIL TEST*2
/1(UMBER OF �-OACNIN6 -P/T-S_ t� �ELEY. 7g'O �` ELEV. ,DATE aF SOIL°TEST
SIOE LEACH/ING PER PIT SQ, PT. G t6 O T— Q 3 RESULTS AVIrAlESSED BY�
. F�- ` �• �W.� d PER COLAT/ON RATE#/ Ps-sJ MI)VINCH
8oT70M Le�4CH/NG PER P/T so
y Z.� �. „ � Fjft
TOTAL LEACH/NG AREA SQ. FT. Sa s.oljv 6C/�� P1EJtCo -,477/oN RATE A� M/N•/INCH
,QESERI�ELEACNI/VG AREAS SQ. FT.
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SUNIY,IS `�•! pia
Plo.221-1 z ) '_r A�may° � � EL OR EDGE Ewan VA CO I vc.
712 MA/N S7'
NYANN/O MASS.
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