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LO CAT I N SE ACE PERMIT N0.
VILLAGE 121 foL/
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INSTALLER'S NAME & ADDRESS
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BUILDER ML Ow ER
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DATE PERMIT ISSUED �Z219j
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS®
�_`_OF....... . ... . ... . ..................................... W Q
Appliratiou for Bi-span al Worse Tamitrurtion Frrutit
Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal
.. ....... aSy ......................
cation-address or Lot No.
....... -------------------------------
Ow er Address
a ....�.. ..
Installer Address
d Type of Building Size Lot_/1�,_0Q3---Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of ersons._.._.
P� yP g -•••••......-•------------• P Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------------------------------------------------------------------------------••--------------•----
W Design Flow...... F,f.._._....-_---_---••••_-gallons per person per)ay. Total daily flow_____a.,3.10......................gallons.
WSeptic Tank—Liquid capacitylAKU.gallons Length._,/A...... Width___ __________ Diamete----------------- Depth................
x Disposal Trench—No..................... Width....__ ._.._____.. Total Length__.....___......___ Total leaching area--------------------sq. ft.
Seepage Pit No...�_____________ Diameter...ZQ......... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tan ,
-
a Percolation Test ResultsZ Performed by_____________________________________________ _._ _ Date___._.._._____ _ �^
a Test Pit No. 1................minutes per inch Depth of Test Pit...._...?........ Depth to ground water_.___________-__--_-___.
Test Pit No. 2........ minutes per inch Depth of Test Pit.................•.. Depth to ground water..._p.. _77.
xF ------ ----------------------�----------...-•-------;-�---j � � ------•-------------------------------------t--- . ._
o _ -
Description o Soll---�------1�---------• ----�-'--•-�'�----------- - - --------------2------------�----- ---------
W ----••----------------------- ---•---•-----•----••----------------•-••--••-•----•-•-•••••••----•---•----••------------------------•••----------•......•-••--•-•--•••••••-••-••-•••-•--••--..............
UNature 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:T 'LL p of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bepi issued by the board of h I
Sined... • •_•. .............. ... ----•- --•---
D t
Application Approved By.. ----�ZZ�- /----------
Date
Application Disapproved for the following reasons----------------------------•--------------------------------................................................
....••••••-••-•••---•--••--•-••-•'•---•-•-------•-•••----•••••....------•-••••------------•-•-••-•.......I...............................................................-...............................
Date
PermitNo......................................................... Issued.......................................................
Date
No.................... F>$... ..{...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARDPF
EA
-.....4"1,y"-tih .OF.......Y`�,l� �t--�+.� ?!:�-- ------ --------------------------
Appliration for Dhipaaal Works Cann.6trurttun amit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
cyst ..at. ` .-.!4L... ....� . t
v cahonddress or Lot.No.
�........••....................... .....•-----............................... -----•-----........_....._......_..........__...--
�Ow r Address
a - / ✓-�Ci4�/ -- ................................. ..•---......-•-.................... ---•--------...............................
Installer Address ,*�
Q Type of Building �l Size Lot_4��_d���_._Sq. feet
Dwelling—No. of Bedrooms...........0`............................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons___--_ ___ ---------- Showers — Cafeteria
dOther fixes . _ -----------------------------•-•---------•-•-•---•----•-------------------•-----•••••-•-••--•-----•-••...----•----
W Design Flow......... 1_5............................gallons per person per Oay. Total' daiLy flow__._._v3'_5.-......,.___..........gallons.
W Septic Tank—Liquid capacity/ gallons Length___ '...... Width------
Diameter................ Depth................
x Disposal Trench—No. .................... Width..._................ Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No... ............. Diameter...l�........ Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank-( ),
aPercolation Test Results Performed by...............................................' ._ '-�_-s Date_.7•-_..._KA"__-1.___..
a Test Pit No. I................minutes per inch Depth of Test Pit_____!_ _....... Depth to ground water_______..__._.._...____.
Test Pit No. 2.....'r'2-minutes per inch Depth of Test Pit................•... Depth to ground water-____------------:--
R'+ •... ......e ------ ----•--•-•--••-•------•-----�--------------------- -- - <..../..................................................
D Description o.�S. oil -,1-_ = j ' '=.t'`'�•----------�'�- t>°lr" =----�_......- f"-�-r-`----=---C'=°s=X`'-�,'
x f. .`�` 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 i provisions of I
p 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 I .Ith
D to
Application Approved By..... = ---•---•--•-•-••---------- �/_7
r-Date
Application Disapproved for the following reasons----------------------------------•---------------------------------------------------------------•--••--•••----
-•--•---....---•--•---•-------•------•----•----••--------•-•-••-•-`n....................................................................................................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... .......OF......./�.w►✓............. ......... .......................
C9rdifirair of Tuntphatt r
THIS IS,TO CER,T F,Y, That the Individual Se � g is osal System constructed or Repaired ( )
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b = . ..................................................................................••..
I to
has been installed in accordance with the provisions of TI f.LZJ� j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--- . -Z-_ ................ 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 HEALTH
.........OF..................................
No. :%.�.--'., FEE...........- ............
WN.0Permission is..hereby granted--- ... ••--• S= F ! -
to Construct �or Reg ' ) an In ' •j ua- sewage Di s System
atNo.. --: �:*:�... ----------------'�.<_--4---- ..----------------------------------------•-•-------•---------------•-----•----------
Street
as shown on the application for Disposal Works Construction-Permit No___________________o,Dated.._.._.._.._____.__._............_........
/foard of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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LEGEND �
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SPOT ELEVATION ®x®
CERTIFIED. PL®T•
CONTOUR --.— ® —— — L:�iT. ;�rl n�.s'hc•c.K -lz1J �:
)tNED -SPOT ELEVATION
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` T . : . AGENT SCALE= ->G' DATES
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RE�6E ENGINEER CO ONO ,.
CLIENT I CERTIFY THAT THE ® k,
r: ;'.; �c:�C.% � 7 BUILDING SHOWN ON THIS PLAN
STERI: t REGISTEREi9 JOB NO.
'= t,-,. .CIVIL LAN® ®R.®Y � r f' ,r'=a C®IdF®N(�S TO THE ZONING LA _�.
INEER SURVEYOR OF EARNS A� E , MAS
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::SS.•, . MAIN ST 712 MAIN ST.
; ' MOUTH, MASS. IiYANWtS, MASS. SWEET- OF ®ATE REG. LAN® SURVEYOR
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