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LOCATION 4-05 W66DP ury Arc- SEWAGE #
VU LAGE ASSESSOR'S MAP &LOT 3 D —tz2
INSTALLER'S NAME&PHONE NO. L. M.&,Qob„ase,.+ 91,04; $ei✓ae -Sbb 725 5,74
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)3X SDo 6,Y- 04.,f/b (size) yl SX /3 X a
NO. OF BEDROOMS
BUILDER OR OWNER Vcv5 �,
PERMITDATE: �13�otiJ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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LOCATION �� � SEWAGE PERMIT NO.
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INSTALLER'S NAME i ADDRESS
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e U I L D E R OR OWNER
DATE PERMIT ISSUED .2h6 _
DAT E COMPLIANCE ISSUED
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*RVOUIMEALTH: DEPT.
-2ZS' 6 Town Office Building
No...................�7 � South QMqj,, ,MBA 02,664 Ficz............ ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`! � ��
..��....CN.vll-.......OF..... .. ! .. ...--..................................
Appliratiun for Disposal V arks Tonstruriiun Prrmit
Application is hereby ade for a ermit to Construct ( ) or Repair ( an Individual Sewage Disposal
...... ...:..................... ......-------•------:....................
Location.Address or.Lot No.
4/1
.."`�
Owner,7�� � a- �
Address
.........................
. ..-- . Installer--- ........... .............. `�....... ,..�....� '...... ..............---
p� Address
UType of Building / l Size Lot............................Sq. feet
'4
Dwelling—No. of Bedrooms........`.....................................Expansion Attic,( ) Garbage Grinder ( )
Other—T e of Building a , yp g ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------ -•------------------------•--•......-----....--.•---....---------•----•••-••----
W Design Flow............................................gallons per person per day. Total daily flow......._._.._....:....._....................gallons.
.9
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---...--........ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.............--..... Depth below inlet................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.....................................-------
•............................ Date-•-•----------...--------- ...........
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 Test Pit No. 2................minutes per inch Depth of Test Pit.................--. Depth to ground water........................1
O Description of Soil----••--••....................•----.----
U .........................•--------------......---------....----------------•-•--------------------------------.........-•----------•---........--•---•-•-.....`...--••-----
......-•---• ---------------•---------------•-•-----------------------------=-----...--•----------•-------•--C.)_ tr
U Nature of Repairs or Alterations—Answer when applicable._y{_ ......I ...........................P
......................�:10.0.......,L/ ZQ1.---..6...'f-.�'1....��T 2Y�- �.`d �..?�.�? =�' --.� s r0A-�
Agreement: .
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI:'LE 5 of the State Sal, ' — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance as been issue the and iealth-
Signe .....------• --•.............. ............._-
�/ Date
Application.Approved By..... .:-----..................... ------...... ............
Date
Application Disapproved for the following reasons-.........................................-....................................................................
»
...................................................•-•---------•---•------------•-------......-----...................--------------------••-----------•--------------......-------•-----•---•--•••••----
Date
Permit No.......�: .- Ca.I.............. Issued.....................................................
-
Date
r
No. ..........`7(p 1 I a Fics............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�--......OF...... d vt� _� €.��
Appliration for Dispaiial Marks Tonstrurtion Permit
Application is hereby made for al Permit to Construct ( ) or Repair O,,.) n Individual Sewage Disposal
Systemrat ,
.... -. .... -------------------------- -
•-Location Address or Lot No.
..........-• - .___ ... ......... ................................................
Owner c —may .........�.
Address r—'—`""�• ( _ ess -•
►W-a +F-� ! ✓ = 3 .ram b C � ` -- ,,�,vt �?, 1.I+
- 'Installer ----.-. ---•------------------- •.............•...•..........•••...............••-- ..
Address
Type of Building f 1 Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons......_---------__---------- Showers ( ) — Cafeteria ( )
d Other fixtures _
WDesign Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter-..__._-___-_-- Depth................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft
Z Other Distribution box ( . ) Dosing tank ( )
0.4 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water........................
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil
--------•------------------•-----------------------------------------------------------------•--•---....--•••...---••---
V _.......................................................................................................................................................................................................
-
-----------------------------------------------------------------------------------------------------;___-_f-r___-_--.____----.----_--___------___-------..--_------_-------_.-.---------..._..__.....
U Nature of Repairs or Alterations—Answer when applicable_;-.E............................ c Rlr� t`F S ;'
--------------------••--
............................ /) c_Gv -�- n ..t. F- h... .xT t2 ip { 1- + ( rc w 2,
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT%i 5 of the State Sani.tar-y=Cod.�The undersigned further agrees not to place the system in
operation until a Certificate of Compliance(has been issued by�thetboardto=liealth.�
,. Signed- ... 'K`_
_ ._..-•-•-------------•----- .......................... ...
C / Date
Application Approved`BY � �Q ��y c .UU G `- 2•E'--,li-
Date
Application Disapproved for the following reasons----------------------••---...--•--•------•-=-----------•-----•-•------------------------••••--•-••......----
......................................................................................................................................_.._....__...._._.._................._.._..........................
Permit No....... .............. Issued...........................................Date............
Date
.. ice.
1 THE COMMONWEALTH OF MASSACHUSETTS
' BOARD OF HEALTH
..........................................OF......................................................................................
Tntifiratie of TomWittar
TH.{S�IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.........: .:`:::�A 15�..... 9--
Installer '
at....----... ----r•--_. .--- I� -�- -- Q-.... ---►�'�
has been installed in accordance-witlythe�,yovisions of TTTL.�`J5 of The State Sanitary Code as described in the
application for Disposal Works Construction�Permit No... �..�.C�I.._....... dated.............. .......2� �S
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. J
. Inspector.........L; .—,=4.�?-- 4^- ................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' ' '~7� ! .....................................OF...........-----.............................._...._._............................... l �a
No...,.._.. �......%.._ FEE.........:.............
Disposal Works Tonstrurtion Permit
Permission is hereby granted._, C ----- o�' ��--------------------•------- •--..........._.............
to Construct (' ) or Repair an Individual Sewage Disposal System
at No...--,.1...I.A? K' L_ti --\.-1.-n'c rr✓� ,J.� van
•--•- -••-•...............!L-------- ---- ............................................
Street -'7 1•,
/-�l ..
as shown on the application for Disposal.Worl:`s• Construction Permit No_____________________ Dated---------:__._._._.__.._._...............
_ - -,• __ Buard of [reallh
,? ? •j
DATE...........__......... G