80 application and permits CHECK OR FILL IN WHERE APPLICABLE
No — Ens" .t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD,OF HEALTH
OF per - - J -s -'G.! -"i _.
Applirtttiun far Dismal II:lurks Ctunntrurtiun Permit
Application is hereby made for a Permit to Construct (;4 rr Repair (L) an Individual Sewage Disposal
System at: t
ocatio▪n..▪ A
_/-
,ortLot Noy
/ Owner -- Address
C
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. IN Total Length Total leaching area sq. ft.
Seepage Pit No 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
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
Nature4f Repairs or;Altgrations Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE S of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iSsueddiy the board of health.
A Signed s r
Date
Application Approved By 72111.
Date
Application Disapproved for the following reasons'
Permit No Issued ate:_.
Date
by
at
has been installed in accordance with the provisiio of TITL C f 7 The State Sanitary Code a. de ibed in the
application for Disposal Works Construction Permit No • Z"' dated L.� is•L-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE T T E
SYSTEM WILL FUNC/'�,1ON/$SpATISFACTORY.
DATE /°%" Z/ .?'- Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
71 I
ertifirate of flnmplianrr
THIS IS TO CERTI l t th Indi baI Sewage Disposal k79 ed ( ) or Repaired ( -t
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
of Al
3itn.pnnttl
P.E
into Qlunntrw#inn lrrmit
L
FL✓E./..L:....0 .i
Permission is hereby granted
to Construct ( ) pr.Repair (L-') an,Individual Sewage Disposal Systeu✓' r
at No - if
L.i. / l�v F'-° C.,.r ilk:.�i
. ' 7 Street
s
as shown on the application for Disposal Wo▪rks Construction Permit No— Dated
DATE
FORM 1255 A. MSULNIN, INC.. BOSTON
Board of HFalth
No 4
\ t,
TIM t.
ppINNIS
Ap�FBt rn idiwalnt
C(OYI ION\i'F, Lif OF MASSACHUSETTS
Board of Health,41 1/% . MA.
TION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
p
Owner's Name -pi c fl3 , Ay Al
Loc< i$ NIRy (/JPt
Address MORkilN� 610E. (.}aiVVt- SIRAaNRN\
map/Parse ..
Lor# il 41 - 1V10(ZA%L�S�-CIS
Telephone# 4,4 112-- p l I0
/
Installer'sName /1b '.%l /1 /W '
Y
Designer's Name i I yyl 4 M 46.//{ V) S
Address '16 IV\O k&Vt RD- W r r7,P✓s TtAddr
Telepl te#
T l ph ne# (.14 )3) s z%- 52 9 /
Type of Building Si N&)-E TAmIll I.ntSize sq.ft
Dwelling-No.of Bedrooms 3 )
Other-Type of Building No.of persons e Sh : 6eSetewn( )
Other Fixtures
Design Flow (min. required
Plan: Date
Title
Description of Soil(•
Soil E aluamr Form No
30 gpd Calculated design flow 3 J" Design flow provided 480 gpd
Number of sheets o— Recision Date 3-3-
osEp u85t' AGE SEw;6 _sl •ow 3. Sd✓1
L /oRarei. S fl4 f�fSS
Name of Soil Evaluator �t r ���SC Date of Ecah'anon
DESCRIPTION OF REPAIRS OR ALTERATIONS I Ep(tcicx FU Li c . So/L Ar2scaiof ?0A)
SysTen aiky - nesTfLL- v0 3 5,45 oN Lsr 9/
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
de�sJ �
further agrees t of to place f '9 % oper ion until a Certificate of Cott E ce has been issued by the Board of Health.
Sign( -'y �f. r 9y%�-Ci�- Date /%1//
Inspet mots
S
COMMONWEALTH f)��F IASSI IIUSLTIS
Board of Health, 4/ rill; )taW.Am.
CERIIFICATE OF COMPLIANCE
Description of Work: 3S individual Component(s) ❑Complete System
The under s% d here/by ufc that the Sewage Disposal System: Constructed ( ),Repaired (GY�Jpgraded ( ),Abandoned ( )
bv: I114le K I :/( (/ / i, ( i,,,
at .L 1 7 a y
has been installed in ace/or/dance with their ■jsi 1257f 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No - / date( ? / . Approted Design Flow 47 / (gpd)
I .edge ---7-7 � /1 :,c ,1%' '`'( '� �. .. L� /-�.,)/�([.
Designer: W / ` �yit Inspector: /me `'Date: i
The issuance of this permit shall not be construed as a guarantee that the system will function as designed
e- - FT(
No — /
FEE
COMMONWEALTH OF MASSlCJIUSETTS
Board of Health, 44,444 w1 .
DISPOSAL SYSTEM CONSTI£L'�TION PERMIT
) Repair(/Upgrade( ) Abandon(
Permission is hereby grant to; Consfruct(
a[ _ �
Disposal System Construction'Permit o. ` �7 dated
Provided: Construction shall be completed within three years of the date of this per
O Ce//. GGVt ( �Ct-G
m:1255 Rev 5 9E P M Sulkir Co.'Boston.MA
Date 3-iv. 99 Board of Health
FEE
an individual sewage disposal system
as described in the application for
x�it, I locjLconditions J..kie met.
No.
1p
FEE
COMMONWEALTH OF MASSACHUSETTS
Board of health,NORM?,II"lP! (•'f� .MA.
ATION POR !DISPOSAL SYSIEM CONSTRUCTION PERMIT
Type of Building
Dwelling-No.of Bedrooms
Other-Type of Building No.of persons 4-7
Other Fixtures
NGLE
ram) y
lot Size
sq.f.
Gmb�agg/e rindrr( )
Showers(10. - ete...-.' -
Design Flow (min.required) S1%0
2 n (�v gpd Calculated design flow .3,2 O
Plan: Date 9- 6- 7 Number of sheets a--
Title PEA O'
Description of Soil(s)
Soil Evaluaor Form No.
Z` V4 " G 1Ci an9
Date of Esaluation U ✓ (a
Design flow provided 359. 0 Lilfgpd
Revision Date
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS tiZ 03)L) & 6- SO it- 2 oP ?1A)
1(
r99
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 Date
Inspections
location {�. 0 C CO qJ
Owner's Name'1»QO')p, rn ail/1
-0jArR
Map/Parcel# ,_/ //
Address
Twit
Telephone#
Installer's Name
�y
Designer's Name...rim U1v ei,e) uum,s R ?
Address
Address r
Add (U fn rsn
vo /icioa Reap-C.(J their/e7N)
Telephone#
Telephone# 640) 5z,9 - 5zAL
Type of Building
Dwelling-No.of Bedrooms
Other-Type of Building No.of persons 4-7
Other Fixtures
NGLE
ram) y
lot Size
sq.f.
Gmb�agg/e rindrr( )
Showers(10. - ete...-.' -
Design Flow (min.required) S1%0
2 n (�v gpd Calculated design flow .3,2 O
Plan: Date 9- 6- 7 Number of sheets a--
Title PEA O'
Description of Soil(s)
Soil Evaluaor Form No.
Z` V4 " G 1Ci an9
Date of Esaluation U ✓ (a
Design flow provided 359. 0 Lilfgpd
Revision Date
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS tiZ 03)L) & 6- SO it- 2 oP ?1A)
1(
r99
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 Date
Inspections