HomeMy WebLinkAbout0093 EVERGREEN DRIVE - Health 93 EVERGREEN LANE,MARSTON MILL
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_-_ter.+•• .
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...._........o..w-"u.......---OF......a It 2 U.............................................................S I lL Appliraation for Disposal Works Tonstrurtiun Vautit
Application is hereby made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal
System at:
................?J- L_.✓.. G!r�.ata,_�----...L.......................... ......�` ........
.............
ation-Address ^� or-Lot No.
•---•--•--- /� 11 .- �T .Q.11)----------------•-.......----- .....800....Lei 14 ri. ----l.f.AA f...................................
` er Address
a ----.....---M----�-fA1-Jj...-- _N.,J----------------------------•- ----...------14L.1..A..L1J t.►.� ...........................................
Installer Address
UType of Building Size Lot_-Y,?,,.S_Z Q.....Sq. feet
�-, Dwelling—No. of Bedrooms___--.Z.................................Expansion Attic ( ) Garbage Grinder ()!)
a4 Other—T e of Building ....._..... No. of persons............................ Showers
YP g --------•------•- P ( ) — Cafeteria.(..._>.
� Other fixtures .----•---•----- -------•-------•--------------•-----..•-----....•-----•----------------...----••--••----•---------------.
w Design Flow____.__1_�.0___________________________gallons per person per day. Total daily flow......._i°�.q S ......................gallons.
WSeptic Tank—Liquid capacity.l l—R.*.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area.____........._.....s f .
D.
Seepage Pit No........_.4....... Diameter.....�___a_.._. Depth below inlet___Io.'o...... Total leaching area...�_s.-`4...
Z Other Distribution box (✓f Dosing tank ( )
Percolation Test Results Performed by
a ----••------•-••-----•••---••-•------•••••-------------------------------- Date------------.._..
Test Pit No. 1....2........minutes per inch Depth of Test Pit....lz -0"-. Depth to ground water....No_N;t 7
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
I •---•--••-------------------------------------------------------------------------------------------.....................................
0 Description of Soil..........5_A IJ.Qj....-- (? A1 rl..............•---•--••------•---------------------------------•------------------------...---
x
U -----•--•-•-----••---•------•--•---•--•--------•---••.................•-------..... --------•---------•-•-•--•----------------••-•-•-----•---••--------------------•-••-----------••......--••--------
w
VNature 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 th State Sanitary Code— The undersigned further agrees not to place the system in
op r 1 a r0 ,cat pliance has been i sued by Oje board of health. n
>gned !� 4 F
�( ��� '-' -
e
Application Approved By.............
Date
Application.Disapproved for the following reasons________________________________________________________________________________ —---- •----. ......-•------
............................................................•----•---•-••---------•------.......-----------------------•--•--••--•--------------••-••-•--°--------------• ----•------------•---•-------
jj Date
Permit No..... ... __I.............. Issued.........L �J - -.......---
at
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
I A ,
m / �C(�J IL
DATA
No.. . ............... Fxs. .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-------------f--------`'...p- -----.....OF......!..`.:..h.!. .........................
Appliration for Dispvii ai Workii Tomtrnrtion thrmit
Application is hereby made for a Permit to Construct (X ) or Repair ( } an Individual Sewage Disposal
System at:
� - 1 •- � � t ICI h' t -{., / / •: I l� I 1 '
................_- - .............-----•-•---...............••-•-•....................._... -••••-•-••--..................•......... •-•-•----•---••••.....---•--•----•--•............-••-
Location-Address or Lot No.
—- ..0 .. -dress .......................................
{ , Owner Address
At
----------------------- - -
Installer Address
Type of Building Size Lot._`/...... .....Sq. feet
Dwelling—No. of Bedrooms........:H.................................Expansion Attic ( ) Garbage Grinder (Ss )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ..__... -•---•-------------------------------------
w Design Flow.......k..1................................gallons per person per day. Total daily flow..........!_.................................gallons.
WSeptic Tank—Liquid capacity..,.... 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..............!...sq—ft. ,
Z Other Distribution box (Y-') Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I..._`.::____.._.minutes per inch Depth of Test Pit----t_ ............ Depth to ground water__________ __________
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a .....................••......................................................................................................................................
0 Description of Soil------..... '1.1...-1 ` !:.A.:�': f--------------•---•--•----•----••---••------•-------••••--•--------••---•-------------•--•--......-•--------------•-
x
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 TIT1Z- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certi to o pliance has been issued by the board of health.
14P l
f J /
Signed.....................-'........--------•-•---------•-------....._-----.-- f.�_%�?.e_l..:.
� f f L4 L'�5, — -- `Date•i -
t
Ap�i�atiori Approved By........s-=--=>-.I= .............................. ..,.:.....: ' _= '-
-' �---C_Dat�-----
Application Disapproved for the following reasons:............................................................................•-••----- ---------
-------------------------------------•-•--•------------•----=-------•-•------------•-•••-------•--•-------•---------------•---•••......-•----------•-------............................................
C/ Date
Permit No.---.... 9 ._ _i_. d -. Issued_.........
i -
Date
THE COMMONWEALTH OF MASSACHUSETTS
' a BOARD OF HEALTH
..........................................OF...........I..........I............................................................
(9rdifiratr of TontpfiFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( I or Repaired ( )
by---------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at.--•--------------------•--•--•--••••-•-•-•-------•......---•----••-----•=-•--•-----------------•---
has been insalied'in accordance witli the provisions of TITLE 5 of The State Sanitary Code as described in the
application for;Disposal.Works Construction Permit No.___ �-.__•.'i--_:.3._"_.......__...... dated........... ..........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT-BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL FU TION-SATISFACTORY.
DATE................��-.�` 7 __9_5....--•-----------........... Inspector.....................- --
;f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�--- �� - C1 OF.................................................•---......_.........................
No_
r-• •--••- FEE:......................
Disposal Vorkii T-Ennotrurtionpamit
Permissionis hereby granted..............................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo.................................................................5
...................-----------------•••--•------------•------------••--•-•---------•-•------•----....•••--
Street
as shown on the application for Disposal Works Construction ,Permit No..................... Dated..........................................
----------------•-------•----........-------------------------------•-•--------------•---------•---.-----
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
- i
)
0 ftimorweM of MOSSOC�'1Usetts
.- - John_Graci
-- : " Exet flue=C ce of ENronmisrrtaf �ffidrs _
- - D.E.P.Title: Septic Inspector
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- P.O " ox 211`9
t e-t MA 02536.
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nyirion !'�e�� ' !'� �t�' t� � �,,� b 08)`5'64-6813
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SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSRECTI ORM:
_ PART A N.
4 CERTIFICLiT10N � C9
'Property Address. 93 EverGreerpEW.Marston MRs Address of 6wner
Date of"inspection;91z019s {If different) _
Name of Inspector:John Graci Y+layrie Chasson
company:Name,Address and Tele,plaane.liturnbsr
CERTIFICATION STATEMENT
I certify that'I ha—)personally inspected the s".wage disposal system at this address and that the information reported below is true, accurate
s and complete as of the'time of inspection. The inspection was performed based on my training and experience in the proper funcfion and
maintenance of on-site sewage disposal systems. The system:..
:
x Passes
Conditionally Passes,. _
Needs Fu' er Evaluation By the Local Approving Authority
_ Fails
1ti Date: gnolgo
Inspector's"Signature:
The System Inspector shall submit a copy of#ws inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system cT has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection..
The original should be sent to the system owner and copies.sent to the buyer, if applicable and the approving authority.
j
INSPECTION SUMMARY:
Check A, B.'C, or D:
A] SYSTEM PASSES: .
x I have not found any information which indicates,that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not'evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair, passes inspection.
r
Indicate yes, no, or not determined(Y,N,or ND). Describe basis of determination in all instances. If "riot determined",explain.why not.)
The septic tank is metal;cra ked,structurally unsound,shows substantial infiltration or exfiltrabon,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street • Bostoaa Massachusetts 02108 • FAX(617)556-1049 r Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A _.
CERTIFICATION (continued);
Properly Address: 93 EverGreen Dr.Marston Mills - -
Owner wayne.Chasson _
Date of Inspection:9120196
-Sewage=backup-or breakout or-high-stati.c_water,leyel observed in the distribution box.is due to a broken,
seitTed o�une n distribution box; The syctenrwWpess"iiaspectian if(vath approval of the Board of_Nealthj _
F _ _..
broken pipes)are replaced.
_ obstruction is removed
disiribution box is:leveled or replaced
The.system required pumping more than four times a year due to broken or obstructed pipe(s). The. -
system will pass-inspection if(with approval of the Board.of Health):
" broken pipes)are replaced
obstrucilorj;is removed
i� C] FURTHER EVALUATION iS R.EQUIRED BY THE BOARD OF HEALTH:
i,.
Conditions exist which require further ev aluafion by the Board of Health in order to determine.if the
system is failing to protect the.public health, safety and the environment.
1)" SYSTEM WILL PASS UNLESS BOARD OF-HEALTH DETERMINES THAT THE SYSTEM 15
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT-
Cesspool or privy is +vithin 50 feet of a surface water
Cesspool or privy is Within 50 feet of a bordering vegetated wetland or a salt marsh.
.2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER; IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN'A MANNER THAT PROTECT THE PUBLIC'HEALTH AND SAFETY AND THE
ENVIRONMENT: >:
The system has'a as tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tar,:and soil absorption system and is within a Zone 1 of a public water
supply well:.
The system has,a septic tank and soil:absorption system and is within 50 feet.of a private water
supply well
_ The system,has a.'septic tams and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of_ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM.FAILS:
_ I have determined that the,system viciates one or more of the following failure criteria as defined in
310 C M R 15.303. :The basis for this determination is identified below. The.Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facj*or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of.effk:ent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
` (revised 11115195)
.2
7.
" - ``" � _ �'- - '._- -`"' _ �".,' '.�`` : yam- _ _ 'x � •-��"�3-
S.UBSURFAGE SEWAGE DISPOSAL,SYSTEM INSPECTION,FORM
,PART A
(cantirweid j -
- Prope[ty Address 93 EyerGreerrDr Marston Wis
Owner: WayneChasson
Dj SYSTEM FAfLSe(continued)
Static liquid level in the distrtbutton box above outlet mJert due to an`overloaded'or clogged- SAS:or cesspool. .
Liquid depth in cesspo'olis less than 6°below invert or available.volume is less than 1/2 day flow. ,
Required pumping more than4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times.pumped
Ari' ortion of the Sol:Absorption System cesspool or,privy is below the high groundwater eleVatton
Yp
Any portion of a cesspool or pnvy is wi#hin.100 feet of a surface water.'supply or.tributary to a surface watersupply
Any portion of a cesspool or pnvy is within a Zone i of a'public well.
Any portwn`of a cesspool or prvy is within 50 feet of a.private water supply well.:,
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water.quality analysis. If the well has been analyzed to be acceptable, attach copy of well water,analysis for
coliform bacteria,volatile organic compounds, ammonia,nitrogen'and,nitrate nitrogen.
E] :LARGE SYSTEM,FAILS
The following criteria,apply to large systems in addition to the criteria.
The system serves a facility with a design,flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feel of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply,
_ the system is located in a nitrogen sensitive area(interim Wellhead Protection.Area (IWPA)or a mapped Zone ll of a
public water supply well)
The owner or operator of any such system shatl bring the system and facility into full compliance with the,groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11115i'95).
3 ,
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM
PART
�CHEC T
.Praperty Address 93 EVerGreen or Marston itiAi}s , - -
_ Y ,
Owner.:- -„--- way-ne Chasson
Date-of Inspection '9f,9/96
Check if the following-have been done' -
x Pumping information was requested::of the owner; occupant;and Board of Health
X None of the system components have been pumped for at least two weeks a.n.d the and the system has been receiving normal
flow rates_dunng that period Largz;vclurnes of water'have'not been introduced into the system,recently or as.part of this
inspection.. -
I X As built plans Have been:ob#aired and examined.' Note if they are.not available wtth.N/A
X The facility or dwelling was-inspected for signs of sewage back up ;
x The system does not receive non-sanitary or industrial waste flour
x Tlie site.was inspected for.signs of breakout.
X All system components excluding the Soil Absorption System,have been located,on the site:
X The septic tapk manholes:were uncovered;opened..and the interior of the septic tank was inspected -
' -for condition of baffles or,tees,material.of construction,dimensions, depth of liquid, depth of sludge,.depth of scum.
i X The size and location of the Soil Absorp,
tion System on the site has been determined based on existing information or
approximated by non-intrusive methods.
x The facility owner(and occupants;�f different from.owner)were provided with mforination on the proper maintenance of Sub-.
P Surface Disposal System.
(revised 11115195)
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_ SUBSI�RFAGE SEWAGE DtsPOSAL_SYSTEM INSPfCTlON7FORM
SYS.78 NFOFtMATtON
rGreen.D S< _ __ FL•�OW CON131TI0 _ _ - -
RESIDENTIAL
Design flour: 3�o gallons
Number of'bedrooms. 3
Number.of current residents 4^
Garbage grinder(yes or no): Yes _
Laundry connected.to system(yes or no) Yes .
Sea§oval use:(yes orno): No
Water meter
readings;if a3aitable
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: Iva
Oes'ign flow:o gallons/day
Grease trap present:(yes or no) No
•
Industrial Waste Holding Tank present:"(yes of no) No
Non-sanitary waste discharged to the Title.5'system. (yes or no) No
Water meter readings,if available: Na
Last date of occupancy: n!a
OTHER:{0escri0e4.,,n1a is
Last date of occupancy
> °GENERALINFORMATION
PUMPING RECORDS and source of information
System has iiat been pumped in the lasttwa years.
System pumped as part of inspection:.(yes or no)No
If yes,volume pumped: o gallons .
Reason for pumping: n1a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records, if any)
Other(explain).
APPROXIMATE AGE of all components,date installed(if known)and source information:
1986
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115195)
5.
o —
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,-.
p PART C
S`FSTEM:INFORMATION (corrfinued)'
Property Address 43EverGreenDr,Marstonlftls= _
OW WayneChasson s - -_
Inspection 4120196
SEPTIC TAN'•K x - •. t _
(locals on site plan) '-'
IS Depth below grade
} Material of-construction X concreate_metal_FRP. other(:explain)r
Dimensions:_-L 10'6"H 5'7-W 5'8" ,
Sludge depth:4" -
et tee or baf#le. 24'..
Distance from top of sludge to bottom of volt, "
Scum thickness 21.1
Distance from b p ot`scum to top of outlet tee or baffled 6
Distance form bottom of scup to bottom of o€it;et tee or.baffle:.-16
Comments: -
(recommendat on for•pumping,condition of Or .,and outlet tees or baffles depth of Ilgwd evel in relation to outlet invert,structural integrity,
evidence,of leakage,etc.)
septic tank and all components are structurally sound.Recommend pumping system every two'years for maintenance.
E TRAP:
GREASE
(locate on site?Ian)
Depth below grade: Na
Material of construction _con crete_metal FRProther(explain)
Dimensions`, Wit
Scum thickness:n/a
Distance from top of scum to.top of outlet tee or baffle:nla
Distance from bottom of scum to bottom of oinlet tee be baffle: nta
Comments:
(recommendation for pumping,'condition of Inlet and outlet tees or baffles,depth of liquid level in relation.to outlet invert,structural integrity;'
evidence of leakage,etc.)
Na..
I
(revised 11115195)
6
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_ _SUBSURFAC�SEWAGE-t3f�E?OSAL S`FSTEIUp{NSEEC`C-iQ��R,. .�-
PART C
SYSTEM INFORMATION (continuetl)
x
Propertyrlkddres'S: 93 Ev-erGreen Dr:Marston_MNts - '..
OtiYner- WayneChassan
-;bate-,of inspecfion
91MON _
" `"f1GttOR�HOI DING IAt�yK� — 77
77
(locate on z
Depth below grade nla i
Material of construction__concrete metal=FRP_othe>(expfam).
Dimensions n1a
CapacitY: n1a gallons, j
al to nsLda
Y
_ of 9 -
f to ,
Design -
D .
Alarm level 1 2 - i
Comments _
t
(condition of inlet tee,,condition of'alarm and five€switches; etc )
rda
A.
.. DISTRIBUTION BOX:"
1 (locate on site plan)
Depth of liquid level above outlet invert- n1a
Comments
a (note if level and distribution is equal, evidence of solids carryover, evidence of leakage intoor outiof box etc )
w Na
i PUMP CHAMBER
(locate on site plan)..'
Pumps in Working order:(
yes or no
Comments: "
(note condition of pump chamber condition of pufrps and appurtenances,etc.)
Na .
y`
(revised I1115195)
s h +C
Psi` :4 s T!r^�r >;. �.,,��p f-L*�"�C'T � � �.�i^g}�,��a+ �-.. .- •���.,F'':�x �«- - i � -
x"�d„
SU. SURFACE S15WAGE.DISPOSAL SYSTEM IN,SPECTIOAII FORM
Yam ;,, SYSTEM"ttVFOrt2MATtDN(contlnuetl�" y 3 r=
Property Address. 93 EverGceen Dr Marston MIUs.=.
Owner:
7 Wayne ehasson -
-. Date of`i spe:vdn:.-YM96_
SOIL ABSORPTION-,SYSTEM(SAS):X' =
(locate on site plan,if possible; excavation not required; but may.be-approx:matedr-by non-intrusive methods)
If not determined to be present,'explain: -
n1a
TYpe
leaching pifS,_number: 2 1 00d4alion ieach plts c
Teaching chambers number:nla
leaching gatleries; number.nla:
Yeacning',trencfies:number,�length::Na
leaching fields,number dimensions:
—777
.overflow--cesspool; number:nla
Comments: (note condition of soil,.signs of hydraufc faiiu�e; level of ponding, condition of vegetation, etc.);
_ the.leach pits are structurally'sound and functioning properly. -
CESSPOOLS._
(locate on site plan)
Number awed configuration n!a
Depth-top of liquid to inlet invert: n!a
Depth of solids layer; n1a ;
Depth of scum layer: n!a
Dimensions of cesspool: nta ;
Materials of construction:_ n!a
Indication of groundwater: nla
inflow(cesspool must be' ad as part of inspection)
n1a _
Ka
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
nla
PRIVY:_
(locate on site plan)
Materials of construction:: n1a Dimensions: n1a
Depth of solids: n/a . .
Comments. (note condition of soil,signs of hydraulic failure, level of ponding, condition of Vegetation.etc.)
PrivyComments
Y ..
(revised11115195) _
a
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION'FORM
PART G
s
SYSTEM INFORMATION(continued)
,
Property_Address: 93 EverGreen Dr.Marston Mills -
Owner: —WayneCtasson
Date of Inspection:912t1198 - {
SKETCH OF SEWAGE DISPOSAL SYSTEM:
_ - include ties to at least two permanent references landmarks,or benchmarks
locate all,;.wells,within'1;00' _ -
.y
s
a ,.
A
� P
P�
1
3
{
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet,
method of determination or approximation:
11SGS Maps and Charts
(revised 11115195)"
9 _
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L 0 C A T ION -4t-9 SEWAGE PERMIT NO.
VILLAGE
/li9-12s el A-) 111/1s
INSTA LLER'S NAME A ADDRESS
B U I L D E R OR OWNER
r
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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c 1 �wd lei spa- Z s 8 x 3_14=374;.
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