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LOCATION S I W A G E PERMIT NO.
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INSTA yLER'S / NAME 6 ADDRE S
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8 U I L D E R OR OWNER
DATE PERMIT ISSUED LQ�
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DATE COMPLIANCE ISSUED �,�
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THE C&IMONIVEALTH OF MASSACHUSETTS
BOAR® OF HEALTH A 0
lipfiration for 1isposal Morks Tonstrudion Frruti#
pplication is hereby made for a Permit to Construct (� or.4 air ( ) an Individual Sewage Disposal
stem at: _
........ on-tlddress •- -•-•�-•- ---•--•-•---... ------•--......`._.or _t_.O._........_...••�-
- --•------...........-•--•----•---.... .... _�.. .. ............... -4 :
/� /�,' Owner f,, A dr si
;.s
a ..--1.. ,!�-�..!^` r^-1�d - ----�C+C..z..�� �/L..--•--....... .......................................
e / Installer Address
Type of Building Size Lot...._e!j3L�-7-d.........Sq. feet
�., Dwelling—No. of Bedrooms.......3...........................:...Expansion Attic ( . ) Garbage Grinder ( )
a`4 Other—T e of Building tl1 u v 27 No. of ersons_......�________________ Showers
YP g ._._. ..----•-••-•-•---...- P ( ) — Cafeteria ( )
dOther fixtures ...............................•------.........------.........--------------...._..-------•--•----•-•-••- -••---...... ...----••-••-------••-
W Design Flow_____________________6 .............gallons per person per day. Total daily flow....... ........................gallons.
1:4 Septic Tank—Liquid capacity]S-v__gallons Length--- Width.....: Diameter__... Depth..._-:........
Disposal Trench—No. Width.....::--__.. Total Length.....................Total leaching'-area....===......sq. ft.
Seepage Pit No--------/.......... Diameter.......L. ..... Depth below inlet.._..._.......... Total leaching area...Z ....sq. ft.
Z Other Distribution box ( 1,,) Dosing tank ( )
4 Percolation Test Results Performed by...2! ?:_.4e_ Z?y��`'Y�.�.._......_.. Date...f�7�d/...................
�]
4 Test Pit No. 1_..-./—_Z.-minutes per inch Depth of Test Pit... :Z.. Depth to ground water_.?Ye?{ .......
f=, Test Pit No. 2................minutes per inch Depth of Test Pit._......_'. Depth to ground water....... ............
a ...........-....... � jj
-
ODescription of Soil............................. ... -----------------••-•----•----.......-------•------•----•---------•--..
U ......7r ...... ! _...•..............................
W •••-•-----•-----_..... 2
-----•------•--------------------•-•-•----------••-•---...-•-•-.._..•---------•----..._..----••••••.----•----•-•--------------••-----•••--...---•--•-•...---•-•..._..........._..--•--••••-----••---_•--
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 agrees not to place the system in
operation until a Certificate of Compliance has been issue by t and of h th.
Signed_._���"-----------............. ......
: .. ..........................-----
Date
ApplicationApproved By............. .:/[•-••-•------•••-.......-•---•--•--•--•---............_....---------_..._ _..............�C _ .�-c�
Date
Application Disapproved for the following reasons:-----•-•---------------•-•-•-•--•-----..._._......_..--•---•-------•--.......-----..._------•--•----••--•----
....-•-•••-•..............••-•----------.........._..--••-•-•----••--......•--•-.....------•-........._.----------••••---••••-----------•-•----•-••-------...-••--.=----••-..------•---._...--••--•---
' Date
Permit No..... y.^ /o7`{„r
......---- -•------------------. Issued..........................
..._...----......----....-•---
V
0
No.=...4•
......
Fps........................
THE CCIMMO&VEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............... .................OF
............................................
Appliration for Disposal Works Tonstrudion 1hrmit ,
ication is hereby made for a Permit to Construct V) or,Repair an Individual Sewage Disposal
-system at:
.................
L Lti Address or Lot,No 7
........................................ .... ....
Owner Address
............... ..........
.....................
Type of Building Installer Address
U Size-Lot..../ 7 0..........Sq. feet
....... ----------------------------------Expansion Attic Garbage Grinder
Dwelling—No. of Bedrooms.
Other—Type of Building ... .......... No. 6f persons........ ................ Showers Cafeteria
04 Other fixtures
Design Flow...........................__..._....____gallons 3
per person per day. Total daily flow--_.... .> ,) .....gallons.
------__.____._-..___.......__gallons.
------*........
Septic Tank—Liquid capacityLlx�...gallons Length...�...... Width...... Diameter--..----':___*Depth________________
Disposal Trench—No. ......... Width_.... ...... Total Length.................... Total leaching area....:r.............sq. ft.
Seepage Pit No......./t........... Diameter......../..7........ Depth below inlet.__....q........... Total leaching area... .....sq. f t,
Z Other Distribution box (v) Dosing tank ( )
aPercolation Test Results Performed by.... .... Date.../Z? ..................
........... 1
�-4 Test Pit No. I_,�L.-"....minutes per inch Depth of Test Pit..:;A.Z..EL... Depth to ground, water.Z��!�. ..........
�--q
44 Test Pit No. 2.....:.r........minutes per inch Depth of Test Pit__...___—...__._... Depth to ground water....................
?................. ......*......... .........*----------------......... .......*---------**..........
0 Description of Soil................................
W -
-----------------*-------------------
.......... ...... .....................................................................................
I -
........................................................................................................................................................................................................
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 agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
.. -s-4
......
Signed_.. ...................... ...............................
Application Approved By.............. .......................... Date
.............................................. .............../
Date
Application Disapproved for the following reasons:..........................................................................................................
.......................................................... .............................................................................................................
--------------**------
Date
PermitNo.....: . ..................... Issued................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. .............OF.......... (! ............
Trrfffiattr of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by.....--_........................ ......... .......................................................... . .....................
. ... ...... ......
Installer
at.......... ........I.......... -------------------
has been installed in accordance with the provisions of TITLE, j'of The State Sanitary Code as described in the
application for Disposal Works-Construction Permit ........... dated---------Zz—
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONI;TRUEID AS A GUARANTEE THAT THE
SYSTEM WILL F)JNCTIJDN SATISFACTORY.
DATE..............
...... ...............--- Inspector.......... . . ... ......... ...................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.......'.7...zl:: .OF.. . jf�
...
..... Disposal 1vorkii Tonstrurtion Vvrrmit
Permission is hereby granted----------------------........... .............................................................................
to Construct ( x) or Repair an Individual Sewage Disposal System
at 7 No...............4__........ 7
--------- .... . ...............(,cam_ /....... r
11
-'Street
as shown on the application for Disposal Works Construction' 'Permit Nol*�'_____________ Dated..—. .Z'/..
......... .........
.....................................
I------------------------------------------------
DATE........ Board--of Health
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FORM HOBBS & WARREN; INC., PUBLISHERS H
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. LEGEND
Av
EXISTI.NS SPOT ELEVATION 010 CERTIFIED PLOT PLAN
CXISTI�B CONTOUR --- 0 --
FlNISNED SPOT ELEVATION
L oT 3 1?L 13K 31/ Pl /
Fm SHED: CONTOUR 0 -
r -90* E . .The .location of any: existing under�ound sewerage,
N/: NYA)YA1 /SPokT
wel'ls,. or 'other utilities shown on this plan is approx IN
imate onlyas determined ,from records .and/or verbal
( r informatin,- The contractor .is .responsible for the � `��
:ver f cati.on of the existing locations in the field. SCALE, 3o DATE , 11 /518y
wr:
we ` ' RIGkSiGE ENGINEERING CO. IN CLIENT,'�
• W �S'y i CERTIFY THAT THE .PROPOSED
E4ISTERE REGISTERED 63Y/ BUILDING SHOWN ON THIS PLAN
0 -
t , Sys v JOB N0 ,
s CIVIL LAND OR,BY ^1 CONFORMS TO THE ZONING LAWS
' x : ENOINE.ER RV ' T OF` .BARNSTA9LIE MASS
fi 712 MAIN STREET CH. BYE : BA6
HYANN I S MASS:
' SHEET.- OF ,? DA E E(3. LAND SURVEYOR
2A FT.. /`9//V /11Q7E /F E/T/�/L�/? THE SEPT/C.TA/V/C OR. a e
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TOTAG E.7T/MATED FLONV 3 3 0 0,4L./oA y SO/L TEST Al SO/L 7=S7 2
/NUM&ER OF 4.4-ACN/M6 R/YS I �EtE�K 96b0 FLEY, .DATE OF SO/L TEST
S/O� L�AGHJNG PEJ�P/T LL_ FT. r RSClLTS 3V1T/VE5SE® DY
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