6 applicationa and permits a.
a
.z.
0
U
No
THE COMMONWEALTH OF MASSACHUSETTS
/. BOARD OF; HEALTH
... . .
air .... OF !LQ(°.*0.9212PTt.ct1
Applicatian for flinpnsal e',irks fnnfitriutinn Permit
Application is hereby made for a Permit to Construct (!/5 or Repair ( ) an Individual Sewage Disposal
System inc
QSd :2?YY k eid .40 7 °Si
Address
Owner
Address 7 - ti
Type of Building
e‘i JuezefrArnr,z,
Address
Installer Size Lot_F...i,.L l Y Z Sq. feet
Dwelling—No. of Bedrooms 4 Expansion Attic ( ) Garbage Grinder
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow S .............._.._....gallons per person per day. Total daily flow #-4.0 gallons.
Septic Tank—Liquid capacity/ISO...gallons Length./-0" Width,5=6 ' Diameter Depth e.sa......
Disposal- W—No. / Width.. Q Total Length /0 Total leaching area QOn sq. ft.
Seepage Pit No Diameter- Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by J/me Te.A '716Y ,-.✓c a' Date..:/02-
Test Pit No. 1 0-C minutes per inch Depth of Test Pit._e-47 Depth to ground water A/6We
Test Pit No. 2 " minutes per inch Depth of Test Pit..? 4 I Depth to ground water_dVa.alC
S/i:✓O i s& .7 tw7N ci<tettJ
Description of Soil.6 aelf:&. r fSa.:L., " '-4"
=a
5/c7/ CLAY
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 issued by the board of health.
Signed.
Application Approved By
Application Disapproved for the following reasons'
Date
Permit No
Issued.
Date
Date
CHECK OR FILL IN WHERE APPLICABLE
No I-' ? l Paa..II...31.1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF 4;11l.:.l. y..:P'464
Appliratinn for tspnnat eu orb' nnstrnrtinn Jermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) all Individual Sewage Disposal
System at:
i tAte; em .241:
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 dgallons Length Width Diameter Depth
Width Total Length Total leaching area._1.021.0.sq. ft.
Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Disposal Trench—Na
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
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 RI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the b i.rd of health.
Application Approved By
Signed'
Application Disapproved for the following reasons
Date
Permit No.S.O.Zi
Date
Issued • L/-" .-1._l....f_./-✓._.
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrtifitate of atompliatur
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
Installer
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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
66 Lifisse OF Artirictzw.rfrn
BispnrattLeearksiongtrurtinn litrutit
Permissioniefiereby granted CIELairsIt-A..citt....tetd
to Construct,(p ) or Repair ( ) an Individual Sewage Disposal System
at No......... - A4g4,40,,
FELJS (
as shown on the application for Disposal Works Construction _Permit No-idr,t Dated
Street
-2 e
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of Health
No.t�C`n6 �7
Applicant n for a
'COMMONWEALTH Of MASSA'CIIUSTTTS
Board of Health tip: lk(ittok.4 , MA.
1PPIICATION POP LISP )`s J SYSTLM Ct NSTRUCTION PER
coma ConsvuaO Repair( L'pg de() Aland () - plete System 7lndividi
Location G Coq
IA
Owner's Name
ki, ik.CLA -c till l
Map/Pereel#
1 , c.23 — L)G (
Address
(f) (o�e4ri4 W4/
I �ttc ABC
Lot#
W V 'S`V e, , , ,�„'(Y
I phone#
q
5L (r — .2 6 I
I nstaller's Name
- r 7}�--J . yn. r'
°
I-
signer's Name
ii.)IF. WPtii
Address
---Hr.i-?:{E'�tea'—i �1i�d kQ CC'j��j ,,,(
1 1ddbess
Kf«I1-a4N
LTeleph rek
.#t
(-! t� [ ;y
Telephone#
14iZ, j? j -55 S-L-
;
Ttpe of Building
Dwelling-No. of Bedrooms
Other-Type of Building No. of perso
Other Pisutres
22 SA%
— V75—
Garbage grinder
Showers( ),Cafeteria ((
Desigtl Flow (mit .required) I I C gpd Calculated design flow 33G Design flow provided
Plan: Dam -611\O2 Number of sheets Revision Dare
Title t(-Prl/./ Pi u
t
Description of Soil(s) e.I .f .L 5M'
Soil Esaluator Form No.
DESCRIPTION OF REPAIRS ORALTERATIONS
Name of Soil Evaluato
N(t J
tfPt r / Date of Fiahiatio,
F(i6)r..1
5 , 7eq( 4 L.4k14.
776 jpa (I
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed
Inspec eons
i
Date
c
No.
COMM01 WLAIT)T} ()Lt.
� L/MASSAC1IUSETTS
,t Board of Hrnith. �//'t, ff'Y/L� 1'y AM.
CERTIFICATE OF 1 OBDLIANCE
Description of Work: illi;dividual Component(s) D Complete System
The tinder g red hereby cer,M0 that the Sewage Disposal System; C onstr ted ( ),Repaired ( ).Upgraded ( ).Abandoned ( )
at ,:14,!-r;-74-. q /� Y �� in
has been r sr II d d with th E310 C11R 15.00 (Title 5) and the p-Deed desib i pl s/as-hoilt plans relating to
f . P' I,
ppbcaut i'Vb dated y � F Apprvred Dceig yFlow (gpd)
Installer a- .1 -• t /
Designer: 0.\ - Inspertor: '�(,41171 if,:6— Date: �' �X
The issuance of this hermit shall not be construed as a guarantee that the sisfem will function as d-signed.
FEE
_l ° -14
COMMONWEALTH OF ■IASSACIIUSTTIS
Board of Health, A/A474/106d%lT//L/ ALA.
DISPOSAL SY'STEm CONSTRUCTION PERMIT
FEE �� a
Permission is hereby gta:J}-te-d to; Construct( ) Repair(, Upgrade( ) Abandon( ) an individual sewage disposal system
at (� (Z (t/./1-.0. as described in the application for
Disposal System Constructiah Permit N . .BCD -tt(dated C7/(. *.
Provided: Construction shall be completed within three years of the date of this,perwlt. All 1091 cond s must be met.
Form 1255 Per 5 96 AM.seilrn Co Boston.MA Date r1JC//(!lioard of Health / �L- '%°°t-
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Appliratian fur Einpanal
Fax
arks klanstrurtian lrrmit
Application is hereby made for a Permit to Construct ( ) or Repair
System at:
f >,
•ipnou rAddress
owe
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building t r& l,:iia.
Other fixtures
an Individual Sewage Disposal
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder (✓)
No of persons Showers ( ) — Cafeteria ( )
Design Flow i:.1 gallons per person per day. Total daily flow .3..C_D gallons.
Septic Tank—Liquid capacity/a-ldgallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching area
7,.r.../e!sq. ft.
Total leaching area sq. ft.
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. 1 1 a_
Test Pit No. 2
Diameter Depth below inlet
Dosing tank ( )
Performed by
minutes per inch
minutes per inch
Date
Depth of Test Pit ltd ' Depth to ground water
Depth of Test Pit Depth to ground water
6/
Description of Soil (i - 2"
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:issued bx the board of health.
Signed _ .. .
Application Approved By
ate
if at
Application Disapproved for the following reasons'
Permit No a
Issued
Date
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
L (3. OF
airrtifiratr af alontiftiantt
THIS IS TO,CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
, ,rar —
at
has been installed in accord&ce witlfthe provisions of Article XI of The State Sanitary Code as described in,the
application for Disposal Works Construction Permit No....cal:sr&tir dated ;3/411/-2. /YE ic
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
,j4 ,t
DATE 5., Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Eliopoottl 'hot-Ito (Iloilo tattoo ifrrtitit
Permission iyhereby granted r
to Construct ( ) or Repair (, ) an Individual Sewage Disposal System
at No
6
FEE
as shown on the application for Disposal Works Construction Permit No 7 Dated (
DATE
FORM 1255 HOBBS & WARREN. INC.. PLIBL/SH ENS
Rohnd of liejlth