998 Application & Permit 1998 No 9/
HE COMMONWEALTH OF MASSACHUSETTS
D�%4 19,95p% MASSACHUSETTS
ciNppiicatcan for !Disposal System Construction Permit
FEE ZeG
Application is hereby made for a Permit to Construct( )or Repair S/NQ an On-site Sewage Disposal System at:
location Address or Lot No.
ir!P'TO.I) Lb
Owner's Name,Address an Tel No QM457A
Esr,nr OF Z z,
94{r GJ'7e•mi D, A Pre ad
995 k.2 Z9
E`
% .32Pan%6as 7.4 S8t-ZSSJ
1 talle s Na Address, d
GytvcN�7
A
F'(�,e7
Tel No
Designer's Name, dress and Tel No
iRAciA.I�E
eira Li, y or
�9 5>Yi' oy837Nr✓�c
Pc?
Pc? f4 .01062-
(-
��e
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building No per Persons Showers( ) Cafeteria( )
Other Fixtures
3/ I gallons per day.
Z
Garbage Grinder(NO
Design Flow
Plan Date
Title
the
Calculated daily flow 2-Z-0
Number of sheets
6 »'9S -D4/
Revision Date
gallons
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescri Kon-site sewage disposal
ystem in accordance with the provisions of Title 5 of the Environmental Co e and not to place the system in operation until a
Ilertificate of Compliance h. been issued by is Boar oath.
Signed • A .._.V Date
MWT C ff
C.',.
H ianin
tot rtr:
1pplication Approved by f Date
\pplication Disapproved for the following reasons
Permit No
Date Issued
TH OOMMONW ALTH OF MASSACHUSETTS
/��,7/ 2//1:1--;',7 /V f Th , MASSACHUSETTS
(2er#ifittt#e of (tlnmplittme
THIS IS TO CERTIFY, that the /i
e On-site Sewage Disposal System installed( ) or repaired/replaced jon z
by / -ii� d 1-4 K 1 I for _rt/,.T, 4' •
at i C _,Z.(r t“., Air-ix-s-. has been constructed i
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. L q/- • (" date
. Use of this system is conditioned on compliance with the provisions set forth below
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. Thi
Certificate expires on
DATE , --! - • - Inspector _ !/6C "::74-.
�/ T�-IECOMMONWEALT FMASSACHUSETTS /- Y / r
No. ' 41—?O / 7 4 C�---. /. d ,'MASSACHUSETTS I
FEE
Pispnsttlgs#em klnns#rut#innermi#
n
Permission is hereby granted to — 11-w�-L ( Ii'it i L/s-
to construct( )or repair Sr)an On-site Sewage System located at L r %JL c-� _ / c -
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/he•
duty to comply with Title 5 and the following local provisions or special conditions.
All construction t be ompleted within thhreeeee years of the date below.
DATE construction
T-/ 6 ;.
/ Approved by T- _
FORM 1355 P¢v 3/95 q M 5 LXIN CO BOSTON.MA
•
FitNShHW WtLLUK1LL raX : 41.JLib4D00 Jep U4 u0 11.4U r .uu
Massachusetts Department of Environmental Management
Office of Water Resources
RINT ONLY Well Completion Report
126116
• C ft ,.it"i'1'IG,1'V��A(Q Progeny Owner' .-1 +✓1'+Gtj I • lcdc^'/`'✓tlr
Mailing Address' t� Eas�' ` act
Nerve:
/ream 1• i Clry/Town Ciotttan, V'1l4 btb6O
• s •. . it• m p'bxn
Nap A:.: • - Lot I: NOTE: Assessors Map and of # mandatory it no street address available
Permit Num Date Issued
satm permit oMeined: Yes ❑ Not Required Cr Sr
•MBE, "
ci nR1ELMI PA 1tr11oo
❑ Cable 0 Auger
Air Hammer 0 Direct Push
0 Mud Rotary ❑ Other
all ❑ Abandon Domestic 0 Irrigation
i ❑ ReconMtIOn Monitoring 0 Municipal
e 0 Other ❑ Industrial ❑ Other
•,,,,;,;�
vmrreary
Consolidated
0.!�F1iE`ek�ifieiw�le'�a+M`Mn�.�a.mi
9
„ �
To (m) 3
(a
oUnconsolidated
w
to
u
e
$
Other
Rock Rock Type
High
Low
IC,'
11a.•,1 9,7
ac--c-,---.
if
3
114 '
1954
P' nay
•
�a
�8,"7�1�,
FA
��
L140'
F om (h) To(It) Casing Type and Material Size O.D. (in) Well Seal Type
th Drilled
ng Complete
• •
0 L t.
to I •L
Si•.a
...
To (It) Slot
Size Screen Type and Material Screen Diameter
To(ft) Material Description Purpose
Developed? ❑ Yes ❑ No
Fracture
Enhancement? ❑ Yes dallo
Method
Disinfected? Yes ❑ No
Yield Time Pumped Drawdown to _ Time Recovery to
Method (GPM) (leis&min) (Ft. BGS) (hrs& min) (R. BGS)
Date Measured
Depth Below
Ground Surface (FT)
5 Ca 'r
#& Yap'
S'
3o
g .2 7_03
30
f. ,4.r
•... r �. C�'r L1
It loAtaiNknAtPliettLe00005ANI"'
�e l %E L. •vQ, Horsepower
i hp
ca.M.2
ecrgton
eke Depth • (h) Nominal Pump Capacity (gem)
n
•
• v`L
This well u was s,and the rr report is abandoned und r my supervision,to best of my to applicable roles
(� end regulations, end this report is pleteya/nd correct fo me best of my knowledge(.? I
�/ Registration Id I I -`i FO1
Ui %'r et Supervising Driller Signature: iv �^'-'�
ai I' . .l' IS As Date' 'i7-O 3 Rig Permit n'
NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion.