350 Septic Application Permit & Compliance CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_.+. 1– OF..__Kir_s i-� ar, JAG I
1 ppiirtttinn fur ljispnsttl rF Darks Cnnnstrurtinn 1ertnit
Faa.
Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sltrayag&LDhiposat
System at: '”'=h,,.t..,s-tort
o I'
ti , ..i, .. 1'1
Location•Address
or Lot No.
i.:::._....IL., d.
Address
-.1
Installer Address
Type of Building Size Lot /' - ' '% Sq. feet
Dwelling—No. of Bedrooms i 1 Expansion Attic ( ) Garbage Grinder ( j.
Other—Type of Building No. of persons Showers ( ) — Cafeteria (y )
Other fixtures _
Design Flow gallons per person per day. Total daily flow ''f0 le t ions.
Septic Tank—Liquid capacity JCC LLallons Length—/" Width ' - O Diameter Depth..Y !mot
Disposal Trench—No. Width -, !- Total Length..../. ' Total leaching area ___Ls e) sq. ft. " ''
Seepage Pit No Diameter Depth below inlet /• - Total leaching area - .(r-) sq. ft. ' t)- -.,
Other Distribution box (/U Dosing tank ( )
Percolation Test Results Performed by 7- / :- 7:—t_-,-);i_t- — L-•e Date - 'f (I ._.1.2 '—
Test Pit No. I minutes per inch Depth of Test Fit._-_ Depth to ground water N#
..
Test Pit No. 2 minutes per inch Depth of Test PiG_..:..._._..... Depth to ground water J -
Description of Soil
At„-. l - .1
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 TITLE 5 of the State Environmental 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.
Signed
Date
Application Approved By
aye
Application Disapproved for the following reasons:
Date
Permit No. ..... . _ Issued
Darr
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
( OF ]Vc_t T _n... R�, „i
Certificate of Compliance
THIS IS TO CEI TIFY, That the Individual Sewage Disposal System constructed ( A ) or Repaired 1
at (' . (. .
has been installed in accordance with the provisions of TITLE 5 of The State Environmental 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
No37-9;
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
flinrnsal nrkn flonstrurtian Permit
Permission is hereby granted — h' . ) '
/1/4 7/�1 s^'
to Construct ( A ) or Repair ( ) an Individual Sewage Disposal System
Street
as shown on the application for Disposal Works Construction Permit
DATE . /4s.5-
Form 1255 <&WJ) HOBBS&WAHnrn1' Publishers
Dated.. /7T7.0
of Health
FEE c r CD
THE COMMONWEALTH OF MASSACHUSETTS ��
/C// / ;, ✓Ipfi ! MASSACHUSETTS
P ppltcattun far ptspoont $getEm lion trurtia t Permit
Application is hereby made for a Permit to Construct(✓) or Repair( )an On-site Sewage Dispo al System at:
Location Address or Lot No.
k( n/ 35C cele5 »1E oe•) kJ.
ICR{ben.eke , /I'1
P 4.
Owner Name.Address and Tel.No.
Set N Nlrlemi
ate (cies Mer.Je..) r�r+�
OfihF.,, phr. , /4.1 C/Cee
Installer's Name, ddress,and T I.No. '.
Designer's Name:Address and Td. No. /9/3) 2T6-fmfi
5 k/Ik yYt Jac,
fri 1M r,
14 P.1114., /sr✓
r
T .
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building
Other Fixtures
Design Flow
Garbage Grinder WO)
No per Persons Showers( ) Cafeteria( )
Lek eu s
allons per day. Calculated daily flow
Plan Date Nn Oko kr/ f5,/9t5 Number of sheets
`Title
Description of Soil
Jp CEWA4E 7ir5Fn44<
A >74r /4 17)
Revision Date
s7t/t4
gallons.
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board ealth.
/V\Signed!(j�— _ �/
A Loved b %�L
Application pp by
Date
Date
///4 7/SS
Application Disapproved for the following reasons
Permit No Date Issued
THE COMMONW ALTH OF MASSACHUSETTS
/Unihr .Y ci:t.1/ MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERT7 tha pe On-sit%Sewage Dis p Lsal System installed � or re�air-�./repl�ced ( )on 72.2 2
by _ :A. 1 (r-
at _ -f '(T r 4_ a _.- has been constructed in
accordantj with}he provisions of Title 5 and the for Disposal System Construction Permit No — 73 dated
/// /7 15I 5 Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certifice all not be constryed as a guarantee that the system will function as designed. This
Certificate expires on / C%
DATE Lars-c , /O /591
Inspector
THE COMM NWEAL)H OF MASSACHUSETTS r
No. 6-5S /v eti?y MASSACHUSETTS
!@iopuz g t m QuStrurtian permit
Permission is hereby granted to n Ate.,-,64,,e/
to construct S,l/) or repair( )an On-site Sewage System located at �r f / 3S0 r.-e -CGn w-`
7g
FEE 53
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
DATE ///(T-V— �I& /y Approved by
FORM 1255 Rev.395 AM.SULKIN CO-BOSTON.MA