45 Application & Permits %'_ . / / va( —
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
civi of Vent 7k.tr►'TUF%
Ft[ 5o GL~
APPLICATION FOR DISPOSALSYSTEM CONSTRUCTION PERMIT
Application rot a Permit l r Construct f ) Repair f ) t p fade If /Ahand-o E Complete S.stem I Individual Components
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Lnlitt sanl
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t`tftcs
Type of Building: SI'- 04-' 9{LIMG
Duelling—No.of Bedrooms /( / /A
Other—Type of Building I / / /--F-No of person
Other fixtures /V t l
Design Flow (miry reqpired) /gpd Calculated design flow gpd Design flow provided gpd
Plan: Date C"/ /% 4 Number of sheets Revision Date
Title lfl _ ).s'i%d/ ) C7 it v%r/G l/LOX-- ,•(;ti( 1•
Description of Spills) 1g/r`} / / /,Y.. `x t'1-'11' -
Soil Evaluator Form No. 41/A Name of Sod Evaluator /t�/A I)ate of Evaluation No
DESCRIPTION OF REPAIRS OR ALTERATIONS
. /%ply 5 hPric 'T-fPY-1 PUNcwT vE. lJcltel-j 9- e// df7 "As 1-14ILC-
( NiAA!Nb Up TD - c. lif 5 tin cg =-i 4'p
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further,ogrees not, pla the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _ t•-to '-
Inspections%t
Lot Size Sq. feet
Garbage Grinder (tJ),41
Showers ( )_ Cafeteria (
)
Date
FORM I - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
Na
Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS
10iA701 YYr4N BOARD OF HEALTH
A CERTIFICATE OF COMPLIANCE
Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ). Repaired
at Ny ' /dl td lye % C1-!(<;,-'�'- Iii; `tdN : h.4 . 0 1CIaC) -
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved des
plans relating to appVafton N0.4 7' , 'r:-i dated ) !!O/.`, . Approved Design HIM
Upgraded( ).Abandoned/S4)
n plans/as-built
L (epd)
Installer .3'h;'
r
Designer: c-X -?; s Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No.JVC ' GI THE COMMONWEALTH OF MASSACHUSETTS FEE
"i-PHYIPTUN BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereb�y.granted to Construct ( ) Repair ( ) Upgrade ) Abandon ( ) an individual sewage
disposal system at q7 C'93b)RN/t'e / C tck- A .TaES` /-( 0:c(e 0 as described
in the application for Disposal System Construction Permit No e2 f -/...-r f .dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
��y i
Date "%f7"-9, ` 7-/ 7 , t%U. Board of Health ///ts 4/.2'63+'(14,),„_--
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 OREV 5/961 ( II&W / HOBBS fl WARREN,v
PUBLISHERS BOSTON
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,OF HEALTH
OF
FEE
i
ippluatinn 'tnr Bispnsat mho Oinnntrurtinn l3ermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
Owner
Address
Installer Address
Type of Building Size'Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area.
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I 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
sq. ft.
Total leaching area sq. ft.
Description of Soil
Nature of Repairs or Alterations—Answer when applinb le_:-___....:.y..,.r:,..:_ J
r.. -d .s
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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.
I .
Signed s
to
Application Approved By x,: ti i E t1
Daft
Application Disapproved for the following reasons'
Permit No
Issued
u
2L1
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
atertifirttte of Tr mplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
mstaBee
at ,. �. . .....
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector yt.i.::!: ... !t...:.i Y'•+
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
flinpnnal Harks Tunstrurtinn hermit
Permission is hereby granted.,
to Construct ( ) or Repair (11 an Individual Sewage Disposal System
r
FEE
street
as shown on the application for Disposal Works Construction Permit No
, r
..._....-ti..j
DATE
Dated-Z.Z.x«._w 7' J
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
•
Board of Plealth
CHECK OR FILL IN WHERE APPLICABLE
No.91-5-4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
OF C-1. 714410
Appliratinn for Dismal Marko QInn trurtinn 1rrwit
FEE
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
2,0
or m.
Installer
Address
Type of Building Size Lot//4.COc± Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacitAa...gallons Length Width Diameter Depth
Disposal Trench No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area3.0.O..sq. ft.
Other Distribution box ( ) Dosin°y-� - )
Percolation Test Result Performed by...l_..l...t.. _ Date 6-e.k -(,7
Test Pit No. 1 minutes per inch Depth of Test Pit. .. t Depth to ground waterneS..e-+t{-_
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of So�l...i_.0. ..__4.# - �S. — -t_tLt. ..i '�.I„C� ,(C[.L,.O-<.L.!-t,�te.
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been isstd by,the boa of health.
Signed fs
p 1 �,/ use
Application Approved By S.Q. S..Rs'...-1-1...../l t -sd-g�..tpa /.�..l.Q�i.�
0 n �
Application Disapproved for the following reasons
Permit No
124.1