289 Septic Applications Permits & Compliance /4. 83
No i 43
THE COMMONWEALTH OF MASSACHUSETTS
.P}tplirttttnn
BOARD, (JF HEAI-THC
OF N
Ar Elin}lnnttl
IiE
Application is hereby made for a Permit to Construct
System at:
N Oar
FEN I . Cc-)
nrkn Cnnnntrurtfnn rrmi#
or Repair ( ) an Individual Sewage Disposal
Lot
a
Installer
Type of Building
Dwelling—No. of Bedrooms Expansion At
Other—Type of Building No. of persons
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity
Disposal Trench--No.
Seepage Pit No
Other Distribution box ( )
Percolation Test Results Performed by . r
Test Pit No. I minutes per inch Depth of Test Pit /0
Test Pit No. 2
mi . tch D@ of Test P�
c
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
gallons Length Width Diameter
Width Total Length
Diameter Depth below inlet
Dosing tank ( )
Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
Description of Soil
/
A
Date
Depth to ground water
afpth to ground water
/ Sig 3
.�N.tr-r✓L_
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—TNe undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue Y)the boa le alth. /
-fig .., /4 ,-,-.ri-
Application Approved By
Signed.
Application Disapproved for the following reasons•
Permit No
/ G
Issued.
Pate
Date
by
at
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
rrtifirttte of (umpliattrr
THIS IS T RTIF -.t the Individ ewa e Dis osal System constructed
g P l ( or RepAired ( )
Air
has been installed in accordance with the . ovisions of Ty'EL rof The State Sanitary Code sles b d in the
application for Disposal Works Construction Permit No /4.--F• ,� dated bb
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED Aj)A GUARANTEE T T
SYSTEM WILL FU CTIQN SATISFACTORY.
G
DATE p Sri/2 Inspector r .�
No 11 _Q
THE COMMONWEALTH OF MASSACHUSETTS
BOARD /-Op/HEALTH
OF f 1�l-3-L.
3�4SpoStt1 ko ttstrurt mutt
Permission is hereby granted
to Construct ) or Re
at No ..
Yf
nriivi a1/Sewage D osay System
Iv.rwpi ;Mfr.?
1
as shown on the application for D sposal Works Construction Perm' o. _V ' Y3 ated. .. ..4 Y
DATE 0 �" 3 � Health
No. 3/— a 3
ORIGINAL .t
COMMONWEALTH OF MASSACHUSETTS ?i R-. . ►_
Board of Health, AC?i-Vicimpier\
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair()c) Upgrade(K) Abandon( ) - 7 Complete System Q Individual Components
Location agi
/-tq}FiCld. S+-,
Owner's Name Dovi`f%( Roo
Map/Parcel#
t/r
Map i `
Address
Lot#
/Ci
Telephone#
Installer's Name
Designer's Name A Ia h uei(s s
Address
Address i2eI cIi- t J-tw
Telephone#
Telephone# pL3 X13 —5lt 57
Type of Building
Dwelling-No.of Bedrooms
Other-Type of Building
Other Fixtures
Design Flow (min.required)
Plan: Date
Title Sep{ c
Description of Soil(s)
Soil Evaluator Form No.
0c-sic/evict
3 ReartzarIS
Lot Size
No.of persons
yy Ac rc et'fr.
Garbage grinder(y)
Showers ( ),Cafeteria ( )
S
/10 gpd Calculated design flow
Number of sheets Revision Date
PC,5fcm 2tp it f' n
Meet - lcorze 55nCJ
3 3 6 (995,)Design flow provided 5/C. gpd
Name of Soil Evaluator 4, (Ai c i c5
Date of Evaluation Ti/6/o3
DESCRIPTION OF REPAIRS OR ALTERATIONS 1b-'C+-611 IVew S. /gnft aria( L. art nICS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ees to All to place the eemin_operationn until a Certificate of Compliance has been issued by the Board of Health.
4 Signed) . it�A A !�7 ( -G/LLKt C%-`lC Date 7I 3/0
Inspernuns
No - FEF�_1 -
COMMONWEALTH (Jr MASSACHUSETTS
Board of Health, NV(?4-14 /) /'MA
CLRTICICATL OF COMPLIANCE
Description of Work: ❑Individual Component(s) Complete System
The untlersigned hereby certify that the Sewage Disposal System; Gnus acted ( ).Repaired (Zs rpgr d id O Abandoned ( )
C _ l F 1 L /, LF t Y- -71-1/7 i, ( C)r !.Lc,/ -1j
f'1� Y-7,' I'S tF / —+
has been installed in accordance with theirs i ions of 310 CMR 15.00 (Title 5) and the approved design pl tan/.co-bc It plans relating to
application Ns, y— ` -51, dated " i/to y C. -. Approved Design Flow c/tIc (AJAdl
Designs l ' j Inspertot' )i ' a Date: -The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH 0L N1r\SSACIuI s-JTS
FEE
DISPOSAL SYSTEM CONSTRUCTION PFJ M11T
Permission is hereby granted to; Construct( ) Repair(/) Upgrade( ) Abandon( ) an ind iridual set cage disposals stem
as described in the application for
ii
Disposal System ConstrucuoN Permit No. s dated 2( .'
Provided: Construction shall be completed within three years of the date of tips perm] All local st be met.
f
FAT 1255 Rev 5/96 aiM.SWpe Co.BUS10n,MA Date
.
-'I- le Board of Health t e