29 Applications & Permits CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application for Disposal
1:r
ovaA pplication is hereby made for a Permit to Construct
Systm at:
t',71v= LN J'N€ GFIVF
j...........----_ Location-Addro,
PAGI. JiI'd KI
Installer
Type of Building
1 Dwelling— No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow ` gallons per person per day. Total daily
Septic Tank-Lioruid capacity'' gallons Length Width
Disposal AkRriesl?t -No. 1 Width s Total Length -
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by -d `' it I,I l E1 . , _'.,. , INC. Date - -"
Test Pit No. 1 - minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
arks @Innstruttinn jrrmit
or Repair ( ) an Individual Sewage Disposal
lE
e<(AY
or Lot No.
Oi£i 1. lilt 1 : , !'.• T..
t tiaeren
Size Lot - S¢'feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
flow gallons.
Diameter Depth
Total leaching area ' .. , sq. ft
Total leaching area.. sq. ft
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 TITLE 5 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.
Stgned.. Ili T .._.. ' <. .............__
D ¢
Application Approved By :L < /„ ? i:F Date"Application Disapproved for the following reasons' •-
Permit No
Date
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
er--/ or
Olgrtifirate of atotttplianct
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed OiC or Repaired ( )
by A-7:r trAtV/'---MQ
at 47r A Da /73121-7,7
ELi a.c..an9
has been installed in accordance with the provisions of TITL E 5 of The State Sanitary Code as described in the
application for Disposal \Vorks Construction Permit No - ed
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE 5 A GUARANT97tHAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE cotty kW/ 1f73 Inspectoroe-C---/taatne:
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Disposal U litho Tonotrurtion Permit
Fee
Permission is hereby granted
to Construct ( c) or Repair ( ) an Individual Sewage Disposal System
at No
as shown on the application for Disposal Works Construction Permit No -_ Dated
DATE
FORM 12 55 soon & WARREN, 1 NC, PUBLISHERS
Board of Health
CHECK OR FILL IN WHERE APPLICABLE
ME-0 g
THE COMMONWEALTH OF MASSACHUSETTS
OARp 'CA HEALTH
oF G%7>'i1L/
Appliratiuu fur Uispasui Marks (gauntly. remit
Application is hereby made for a Permit to Construct � 3 Wal pis
PP y ( ) or Repay ( an Indivi ual Sewage Disposal
System at: j
FEEL .ice'i 6 V
c} AL
a Addecss
Gtt"ire ✓
ela
Ins[enev —7 t '� -0/ 8 Address
Owner
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder (NC)
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow
a It ' zv
Address
H“t.o gallons per person per day. Tntal daily_flow .4`1.0 gallons.
Septic Dank—Liquid capacity...ExlWt /Length sec._ ui Z
..r.. .. ZKI- than th_ _
Disposal T,.,r.# N . ..Fla$j .. Width 9 At Total Length WV" Total leaching area_(.228.t.S sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box (X ) Dosing tit ( ) /
Percolation Test Result erfor ed by I�f.QYr]QQ Lek,.., �p7 Date S'Zy1 Jo 6
Test Pit No. ]n: _terr�Ixte r inch Depth of Test Pit ( A Depth to ground water _ zt
Test Pit No. 2 minutes per inch Depth of Test Pit �p /Depth to ground water... k}
Description of Soil 1yry,. aters0�rd_a.:(�_Myk.Q._S Oun 5-1+j�p_rys__Ol 111.%
MSS
Nature of Repairs or Alterat' n —Answer when applicable_..1�1.C•wt �2ac�. SF c� f rP7(0�
Cr.�1 D)v e y{
Agreement: "
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of IIITLY. 5 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 th bo'r of hea h.
.. Sig d _ . � Q/o/ i/�G (i1
`'�, .. Date
Application Approved By
Application Disapproved for the following reasons•
Permit No._art.6—0%
Date
Date
Issued
Date
No.
• •
THE COMMONWEALTH OF MASSACH'
oe (uN 7oN BOARD OF 1-i .,.. H
DISPOSAL SYST M CONSTRUCTION PERMIT
( ) U._rade ( ) Aban n ) an in ividual sewage
– / as described
TS
E
Permission is hereby granted to nstruct
disposal system at - —
1-t03 ,dated
in the application for Disposal Sys em Construction Permit No. i�
Provided: Construction shall he completed within three years of the date of this per
Date /�
//Y 9 �e' Board of Health
FORM 2 - DSC DEP APPROVED FORM 5/96
FORM 12551 REV 5/96) B&W> HOBBS e WARREN T"
PUBLISHERS- BOSTON
03
onr