79 application and permits 2005 CHECK OR FILL IN WHERE APPLICABLE
r.
No
FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Appliration for Elisposttl
hF
Ark (Anntrntfiun f rrntit
or Repair (6'') an Individual Sewage Disposal
Application is hereby made for a Permit to Construct
System at: Q
corapm.-Actives,
Owner
nstaller
or Lot No.
Address
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other-Type of Building No. of persons
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width
Disposal Trench—No Width Total Length
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch Depth of Test Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
Description of Soil
Date
Depth to ground water
Depth to ground water
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
Date
Permit No a .. Issued
Dam
Date
THE COMMONWEALTH OF MASSACHUSETTS
/( BOARD OF HEALTH
Lei.f .. OF 4 Ztt,„ CO
Ot#rtifirtttr of ( athptittnre
THIS IS TO CERTIFY,•That the Individual Sewage Disposal System constructed ( ) or Repaired (VT
by
1 r, (. ^ ��{ as>/ fastaller
has been installed in accordance witWthe proviCkions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No .>LS dated / ../ sL_��k_�.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE „t,r.� i4/4), Inspector —41...4 .._.,if: - a.7lft cvj
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
;.
•
OF i
' I FEE
�ispnsttl arks fQnnstrurfinn tirrntit
Permission is hereby grante
to Construct ( ) gr Repair ic ) an Individual Sewage 'Disposal System
C if
rr;
Street r,
as shown on the application for Disposal Works Construction Permit Ncr. Dated
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
x::(11.
Board of Health
4
No. 261)5=35
THE COMMONWEALTH OF MASSACHUSETTS
6OARD ,q F I-•EALTH
ei7Ly OF Al dliaWtht51)
APPLICATION FOR/DISPOSAL SYSTEM CONSTRUCTION PERMIT
FF, d
Pc T
(14,0
Application for a Permit to Construct ( ) f I yT') Abandon (� ) - [Complete 5 Y st m ['Individual o,
m one'ts
7g COUhtr) LVLL v
) G(40, en--., i7
o«ncrzna�
7y OouiaY 11-'24
Address 1 7.
Cat,- 77 97 ("-Ii
i
wn,tin
2/
Map/Pmmin
Oa3
j Lot#
,6_ ; ,
_
'
tip(
Nr on
oDc�Y T'g n pcu �7'L S
t 1 i �
Add
-2 93
T ynone ir
,-.ft
■ r;N
,' A
'1 r __
ddre
f ' --
r1
1
Teeleytone•
Type of Building:
Dwelling—No.of Bedrooms 9j
Other—Type of Building No. of persons
Other fixtures
Design Flow(min. required 3s� gpd Calculated design flow 43.3et gpd Design flow provided sa gpd
Plan: Date 4; — )5-0 .5 Number of sheets Revision Date
Title PhtT Pl-HpJ ?e)Q 71 re, nt> k%f}Y
hquw 6.;k' $aJ ita-r1.
Soil Evaluator Form No. J/ Name of Soil Evaluator 84 fry 3C.41 r)>° Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
Lot Size Sq.feet Be_ .,
Garbage Grinder ( ) n`,/OHG. — �e»WDe�/
Showers ( ). Cafeteria ( )
Description of Soil(s)
( : kir net4,,»J `1
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TRIE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
FORM I - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
N
Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS
b,yS7-!j BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
❑ Individual Component(%) [2-Complete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ),Repaired(i/),Upgraded(-1 Abandoned( )
/
has been installed in accordai e with th&provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. /^'-z c- dated j Approved Design Flow z f (gpd)
Installer
Designer- ) Inspector �'.:'7(e e %l /,,, 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
THE COMMONWEALTH OF MASSACHUSETTS
"7, n-¢ )i BOARD OF HEALTH tt-4\-.(_ Belt- 7
DISPOSAL SYSTEM CONST?UCTION PERMIT
Permission is hereby ranted tp Construct ( ) Repair ( Upgrade ((Abandon ( ) an individual sewage
disposal system at 41.1(r t'.rl= 2 y ff - F o.,a l l.a-r ,> . t Z.7 r, as described
in the application for Disposal System Construction Permit No c r— - .dated
Provided: Construction shall be completed within three years of the date of this permit-All local conditions must be met.
Date Ea V/2 J-r /'/ ems (': Board of Health LJ1t.,` /ii /a'
FORM 2 - DSCP DEP APPROVED FORM 5/96
A—A AD
FORM 1255 (REV 5/96)
CHh W HOBBS 8 WARREN ru
PUBLISHERS - BOSTON