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123 Title 5 Application/Permits 1966, 1999, 2015 K OR FILL IN WHERE APPLICABLE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH City of Notthampton Applirtttian far Uispasttl tt Fan arks Qlanstrttrtian rrmit Application is hereby made for a Permit to Construct (CX) or Repair ( ) an Individual Sewage Disposal System at: 123 Meadow Stteet Elauvelj Tobaccto°°rarms Southampton Sanitary ? nginceririr CO 123 Meadow Stream Address Feauot Poad, Southampton Installer Type of Building Dwelling—No. of Bedra Nffi"Zai ?' C Expansion oAttic Other—Type of Building ot of persons Address Size Lot Sq. feet Garbage Grinder ( ) Showers (XX) — Cafeteria ( ) Other fixtures Design Flow gallons per person per day. Total daily flow Septic Tank—Liquid capacity b&d gallons Length Diameter Dos Performed by , minutes per in p Test Pit 1V2 n Disposal Trench—No. Seepage Pit No Other Distribution box Percolation Test Results Test Pit No. 1 7 gallons. h Width Diameter De th Total Length Total leaching area... 0 4 sq. ft. Depth below inlet Total leaching area sq. ft. Depth of Date /./ 1-A —4-Co Depth to ground water none Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water Coarse aravel, some silts and fine sand Description of Soil No water to 6' 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 bee issued by the board of health. Signed"11 .h.eraeZf+E.2> 1 6-L.. .4 2 27is 4s Application Approved By Application Disapproved for the following reasons' Permit No Date Issued_ Date CHECK OR FILL IN WHERE APPLICABLE THE COMMONWEALTH OF MASSACHUSETTS Faa `$BOARD OF HEALTH Crr�:4_tey OF / .6.. "RaU'yy�1 Application for flisponnl E'`arka Tanntrnrtion lrrmit Application is hereby made for a Permit to Construct (I ) or Repair ( ) an Individual Sewage Disposal System at: T mvar ss V or Lot No. 11 Ow r Address til Ins:a [1 U p Address Type of Building A 0.rn�t eke,- A^'r` Size ze Lot Sq. feet Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons.._i. Showers ( ) -- Cafeteria ( ) Other fixtures ----_ . .... .. .... .... Design Flow -L.Q gallons per person per day. Total daily flow 8 0 0 gallons. Septic Tank—Liquid capacity-�ilk.tallons Length Width Diameter De th_ Disposal Trench—No..f Width <V Total Length 3,C Total leaching area Depth __I ft. Seepage Pit No ill Diameter Depth below inlet Total leaching area sq. ft. Other Distribution box (1/5 Dosing tank) �q ggggg / Percolation Test Results Performed by hits ......�'u:ab��'...10 Date.._IJ-I F' irk Test Pit No. 1 7 minutes per inch Depth of Test Pit ijd i D pth to ground water •41-021-17— Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water Description of Soil e 2c ?'f -�4Thts.K ..6.�QD AtA eaz-ei:4 Gera. /'2!_?-Altzezd 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 AI of the State Sanitary Code—The and signed further agrees not to place the system in operation until a Certificate of Compliance has b issu ihe o d of health. "ul/Gt/...L, r ".." Application Approved By .bort._ . ..P. 2�.en Application Disapproved for the following reasons' Permit No Q/5./ Issued.. Date /9k s Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF biifictt of Oa fiance THIS IS �0- CE2,TIFY hat th Individual Sewage Disposal System constructed (�r Repaired ( ) by w��.t.LLEN . qq,,'� � � � -- --l��stiller at thiaig■f'- .. has been installed in accordance with the provisions of Articlo he to Sanitary Code as described in the application for Disposal Works Construction Permit No 01..11 dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM ILL UNCTION SATISFACTORY. DATE oZO1tie 7 No .:.;L3)j Inspector., lly. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t scesktion El spanal Works (Ltanatrttttian ermit Permission isilfereby granted ,/ to Construct ( ` or Repair ( ) an Indvidual Sebbage Disposal System at No { :.w<%.!-.ti •-i FEE Street as shown on the application for Disposal Works Construction Permitt No >- ' Dated_f ' � r Y Board of Health LI41 � + DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS FEE COMMONWEALTH OF MASSAC BETTS Board of Health, PLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT et mit to Construct( >Repair((Y pgrade( ) Abandon( ) - Q'Complete System J Individual Components I Location /913 474�77✓/'t)L.0 57— Owner's Name /7 j en/6 7---r--,6 tik./ q Map/Parcel# /V(•/rz///7/ -, /c"c; f'( /4 Address /.2.g /17/. /'Q/01'CU -S./.- p55 Lot# Telephone#/-4.-171_ 4, /c r7 ell Installer's Name W%C Siey.u_tts Designer's Name // _/e C. /a)/J 7 1,,c/ c. // C Address Address ye e a /di/,'l//'</ I �e Telephone# Telephone# /it-L f� /c %/ Type of Building //4 5./8'/'t X- ///lL- Dwelling-No.of Bedrooms 34 p-1/)/160,fr77 /7C, .0/5 /' Other-Type of Building ...51 4,e.",I kr A.71/771e // No of persons Other Fixtures %/Lf-- /> /I! Design Flow (min.required)/%C Y ? < /'l gpd Calculated design flow /%25 Design flow provided --PA-"/ gpd Plan: Date .J/� /%/ Number of sheets / Revision Date '- T1iJ .C:•F A77.1AGr. /,tr-/// C .-e I <<4/31/1 11/ Description of Soil(s) /2/4 A._ /Lc- /71 et-F_ti p_ %52L /-e-e:•_)- /e E' 4-t/'/e,C % t —, / Soil Evaluator Form No. -- Name of Soil Evaluator/C),%5 Min L'2 Date of Evaluation ,��//' t DESCRIPTION OF REPAIRS OR ALTERAT IONS /c.E/J/c> e, F':-.1'/ i ///7c, 716 6//I e-( (A/ T7)4' _ i ' 1/ Cc__/ £ ' /n.r ,/ / % /732 // -7.4: 5 The undersigned a' -es abov -d Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a ees to b te�, r! • e q':on until a Certificate of Co h e has Y s been issued b the Board of Health. Signed �A / ./ ai Date 6111 s f m it r '// / Inspections Lot Size /t-->r/ 5 / sq.f Garbage grinder??�t''/e . t 3 Showers (i,Cafeteria �'C Title lc,'r ILc /J r6c .cs -'C/ //st Description of Work: The underiped here by ^^ at /ci 3 COMMONWLALTFI OF MASSACIES'FTTS AlA. FEE CERTIFICATE OF COMPLIANCE vdividual Component(s) ❑Complete System � � yy�cerdfy that th ewage Disposal System; Constructed ( ),Repaired (.).Upgraded (y-Abandoned ( ) has been installed in accordance with the prow ons o 310 CMR 15.00 (Title 5) an toed design plans/as-built plans relating to apphration No.3 3� 9 gZ dared/' &/ // Approved Design Flow / (gpd) Installer F/�Vt 't"`- ' �(/' Desi Inspector: .f�"� �� 4 /fe"tiate: �O ��S goer. The issuance of this permit shall not be construed as a guarantee that the system will function as designed. / Eft 4,7)M5 EE 3rc.." COMMONWEALTH OF MASSACI-I `SETTS Board of Health, P`'.. (-'. • 7,7-n . DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby //r�a�nt�e�d(,to;; �C��on)�struct( /1 Repair( ) Upgrade( Abandon( ) an indiridual.sewage disposal system at /e,.hereby is- S T as described in the application for � �>, 031(55 Disposal System Construction Permit No. >ry dated Provided: Construction shall be completed within three years of the date of this permit. All local condit}yns must be'net. Farm 1255 Rev.5■96 AM.swec Co.Boston.MA Date (/ I///Board of Health ' - �� No. ZOtS — /o COMMONWEAL OF MASS< CIUSETIS Board of Health FEE /� Co APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ($Individual Components Location Owner's Name f./Op,�< a I4-MM n ciAr Map/Parcel# Address Iti3 F ■Ep Deno STc-EEri Lot# Telephone# 5-3 0 2(p$9 Installer's Name 1-4 -` + Sac, Designer's Name EI.-tgJT OF Address _l 2 Coo S ..S ela� 0 044524 Address oelo.pill l ) 2 9 Telephone# // Telephone# up„ S Type of Building . ..-T--7 Lot Size sq.ft. Dwelling-No.of Bedrooms 0 Garbage grinder() Other-Type of Building No. pegns Showers ( ).Cafeteria( ) Other Fixtures Design Flow(min.required) 1 o X I to gpd Calculated design flow 62&0 Design flow provided 66,D gpd Plan: Date — Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS ORALTERATIONS pepIart n 'i4 j". iIrti The undersign s to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree t o pt E cyst operation until a Certificate IC_o Bance has been issued by the Board of Health. Signed r Date ; IT/��^ Inspections No. ? O - (S / J - COMMONWEALT'l0 MASSACHUSETTS Board of Health, CERTIFICATE OF C1'MPLIANCE FEE//✓D Description of Work: Individual Component(s) ❑Complete System The under/signed hereby c rtify that the Sewyge Disp9sal System; Constructed ( ),Repaired pl,Upgraded ( ),Abandoned ( ) by: /1./.0'14.),e" / r�rajr9/< ///E.nv( at /(.,,c3 / - i/oi(61 /iP/ t has been installed in accordance with the pr ns of 310 CMR 15.00 (Title 5) and the a proved design plans/asbuilt plans relating to �5 l-p application No. t ' dated_�] / Aep,.....d"D.�:g.,[7..a (gpd) , e�I4CC Ir tJOy Installer O-' r P f Designer: Inspector: � — �. Date: 7�7�> / The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. 22:2 (( 1 — /d COMMONWEALTH OF MASSACHUSETTS Board of Health, r'J' -n-n-k"t rat./ MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repai / z 3 MeiMtw s�((L¢g at FE.7/%( ) Upgrade( ) Abandon( )an individual sewage disposal system as described in the application for Disposal System Construction Permit No. ,90 i'/O dated 71617011 Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev 5226 A Sulkm Co.212152222 51A Date % G//lh j Board of Health ��-r -. L- ,r2 //