60 permit and applications THE COMMONWEALTH OF MASSACHUSETTS I'EC
BOARD OF HEALTH
C y OF 1\ior+Vt0.Mt_rtintl
' Applirattnn far Disposal 'gstrm Qlnnstrurtinn Permit
Application is hereby made tor a Permit to Install ( ) or Repair/Replace ( VI/an Individual Sewage Disposal System at:
tO Counte y y
L xnic tAddress 2vher+ Ttiaty Nae 44u 12 bee oad WeISpU,.
rt, Ml1 02790
Oxy« Addma
Nouwrd Envl forum o,-�a1 S'erVtCe5 750 j,io. PISSS9 i+ Si. Amherst- MA 01002
Dcsiulcr 01+x+4[T Addm..
Type of Building Size Lot
,L Sq. feet
Dwelling—No.of Bedrooms 'T Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( )—Cafeteria ( )
Other fixtures
Design Flow 55 gallons per person per day. Calculated daily flow 440 gallons.
Septic Tank— Liquid capacity 1500 gallons Length IZ6 Width 65" Diameter Depth 64"
Disposal'French—No. 2 Width 2' Total Length 75 ' Total leaching area 900 sq. ft.
Seepage Pit No. Diameter Depth below inlet Total leaching area sq.ft.
Other Distribution box ( et-- Dosing tank ( )
Percolation Test Results Performed by 'Mark �{+oNSPSOyt J Peer he Erla�w` Date (o-2-77
Test Pit Na 1 < 2 minutes per inch Depth of Test Pit a 20" Depth to oround water try
Test Pit No.2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil See So;1 Eve unti;oo Fern.
Nature of Repairs or Alterations—Answer when applicable Eeplkce en-Tits Skis-Fern : Sepfic 4ti
1)--Box -Iwo 75' --re.,clocS
Date Last Inspected
Agreement:—The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the
provisions of TITLE c 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.
igned Ss r'' )�!/ Lc !,/ >u i
Application Approved By �C ^--�� /�+ ��--Li~_ 3G/) 3 i i -7
Dail
Application Disapproved for the following reasons:
Permit No.
Issued
Da.
Date
THE COMMONWEALTH OF MASSACHUSETTS
Noh4-kAi1p4OPN BOARD OF HEALTH
eriifiraie of(tnmplianrr
THIS IS TO CERTIFY That the On-Site Sewage Disposal Svstxrn-installed,( pqr Repaired/Replaced ( V)
on _ -� 3r/ 9 -i by �> � r Ilh' ✓,^ \ 41hA
for Imo. hi ) ! `l , „ I , f I2 'E at .G Cr /[_!f `/ • ,/r/.-
.J
has been constructed in accordance with the provisions of TITLE 5 of The State Environmdntal Code Asydesc/ibed in the•application for Disposal System Construction Permit No. ; �-- 7 dated 621-/ 7//!"/
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. This Certificate expires on //�..; i _Li 7') .
mac/ ��
DATE f `-C � // Inspector f-'� .Ltd
No.
CO S MONWE LLTH OF MASSACHUSETTS
P '"i.OARD OF
o v G &An
a m v g •
NY t09 co
mission is hereby granted
HEALTH
fispn l isiem Cnnnstrur{}inn )i r ii
ed to �n�i'C-i � �,.. ,(. .-r f( Y �h� -
FEE E-
F S? Fl
O 4 r�olatruct ( or ReAair/Replace( n On-Site Sewage Disposal System located at
E V. P 24i .__P,-±.1_ �j(L// ,1,...1
w
Efi application P System Apphcant € duty comply
c des bed on the a lication for Disposal S stem Construction Permit.The A licant recd mzn his/her nut to com ly
..CH .a Vii�i1tlle 5 and the following local provisions or special conditions.
c in
c. tilh truction
yc f
EH C i CO HH
st be completed within three years of the date below.
FORM 1255 (REV 4/951 HEWE HOBBS&WARREN'M PUBLISHERS - BOSTON
THIS FORM APPROVED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION
No WO
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH
OF
Appluutiu fur flispu#al arks Tut strurtiun f rrmit
FEE
i
Application is hereby mane for a Permit to Construct ( ) or Repair
4 / System at: ;0
`r./L�r
sag
LirQ
CHECK OR FILL IN WHERE APPLICAB
I ter
c) an Individual Sewage Disposal
f
Aa Jf
Address
pe of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms 2 Expansion Attic (--) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
' •Othey fixtures
Design Flow - ' . gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capaciti&..:_gallons Length - Width Diameter Depth.
Disposal Trench—No r Width • - Total'Length Total leaching area
Seepage Pit No - ' Diameter Depth below inlet Total leaching area
Other Distributipn..box C ). Dosing tank (. ,)
Percolation Test Results Performed by - - Date -
Test Pit No. I minutes ptr inch' Depth pf. Test Pit - ' Depth t� ground Water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
sq.ft.
sq. ft.
Description of Soil
Nature of Repairs or Alt @rations—Answer when applicable
Agreement: - -
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of Compliance has-been issued by the board of health.
Signed
Application Approved By
Application Disapproved for the following reasons
in accordance with
place the system in
Permit No 9.b
Issued
Date
0.4
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7
latrrtiftrate of Olntttplisnrr
THIS IS TO CERTIFY,That the Individual Sewage DiosalSystem constructed (✓) or Repaired (
by - i....zu.c l 4:tt i ea;k1 C
iveAVer
at
has been instilled in accordance with the provisiontof Atli le XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No Ho dated nail /V /y.. :FL.J
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARiNTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE PrIV 6! Mk 3 Inspector
No
Permission i
to Construct
at No 4
40444 tri
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OE HEALTH
Uisjlnsal nrks (dnnstrnriinn
ih
hereby gra t , .,.ems
epai ) yyayIndi%%'rrtt111'a Sewage pisp'osal
as shown o application for Disposal Works Constructs
DATEL T 1// L5 6
2
FORM 1255 Hann hCJWARREN, INC.. PUBLISHERS
FEE