61 Title 5 Applications/Permits 1979, 2009, 2010 4 77
No g / 1
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Fsa...A oQ
Application for fliopoaal Mork t Qlnnntrurfion f rrmii
Application is hereby made for ermitt to3ystruct ( ) or Repair an Indio idual Sewage Disposal
System at:/ /
P CreationAdds
(R...1
Type of Building
. so
S
7 .am aaarett
S
Size Lot .(/$q. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder (.-eac
Other—Type of Building ...ran.gv+12 No. of persons 3 Showers ( 1) — Cafeteria ( )
Other fixtures
Design Flow 4J.Q gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacitynn gallons Length Width Diameter Depth
Disposal Trendy—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 mi tes inch D pth of Test Pi/ Depth to ground water,
in'
/ .
Description of So
Nature of pairs or Item[ ns—Answer when applicable.... fAc
Agree nt: (��
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of TIT LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has hggn yssued by the board of health.
trliree
Application Approved By
Application Disapproved for the folloz
Signed.
L1 /79
Date
s'
Permit No....9...j /
Issued.1/4 l t=:..f 97.f
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtrrtifirntr of t untpltatwr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of Ti T`-.. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATF Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
E7 OF .Q'1�
No _O.. �� 0/
?alumni�! 'arkr Qlonptrurtion hermit
Permission is hereby granted.... ... .. .td-e..t, . ..LCYIA �i:b�+s
to Construct ( ) Repair ( Indivi age Dispo 3jl tem
at No fit.! /�6.Y' �'F._ _dA.?m: �.`i E.
street p / q� pq
as shown on the application for Disposal Works Construction mit o..0_7{ Dated_21.41 4 I-371L- .
Board of Healt
DATE
FEE-ST-67
FORM 1255 HOBBS & WARREN, INC_ PUBLISHERS
No. ao(a Z
PI AI
`(7<v•ce-..r t I} /feTC',e/F
COMMONWEALTH OF fMASSACIIUSETTS
Board of Health, *3tYt�A.pt-Sp'CO*•/ MA,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE /SO'CO
Application for a Permit to Construct( ) Repair( ) UpgradeV Abandon( ) - Cfromplete System O Individual Components
Location 61 li. FalAttc kg -
Owner's Name rict__ 4^'
Map/Parcel*
wr
Address � ( en. /"eeneli /
Lot#
Telephone# 3 aY t'—ey56
Installer's Name
/`I 0 r2 .)41 EXcAV -7--'
C
Designer's Namen�M ,_Jl
Qw� 1�P,Lt.E i—
Address
/
/Y rK to race..e.
/y)avit/
!
Address ' A
/4 �wJ t
Telephone* Cj _, r-,</�1Y3
`�
Telephone#
se v - /8QQ/
Type of Building
��Y
(Q{A.iLd .f,M•q
_.
,s!�
—1 m sbr �axi 1300
Dwelling-No.of Bedrooms a
4
Garbage grinder( )
Other-Type of Building No.of persons _Showers
(f),Cafeteria( )
Other Fixtures
Design Flow(min.required) 2-2-0 gpd Calculated design flow 220 Design flow provided 33O d
gP
Plan: Date pH ii ) (�9p�{p Nu/�m"ber of sheets (y ��""� Revision Date
Tide Fk0.N L V 1 Cirp cep fic Sti mly
Description of Soil(s) iID 0-44.4.a. S0+-tA-
Soil Evaluator Form No. ("L 3 Name of Soil Evaluator Utp»tOA IN&At Date of Evaluation S 0 114/01
DESCRIPTION OF REPAIRS OR ALTERATIONS /K4.4.$)1' ,-t7074;1 ..-•
a•. {`t;,
The undersigned agrees to install the above described Individual Sewage Disposal System hi 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
Na. RO/o -/
COMMONWEALTH OF MASSACHUSETTS
FEE �i71
Board of Health, IV (ni41-e p4071) MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) i Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ),Repaired ( ).Upgraded tom,Abandoned ( )
by: '2tuw Lktmt• 1rryn. zn / tVC
at 6 / 44A.-r4 fn IZ el S #o A /
has been instilled in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicatior)to u/0 /6 - / dated l 7.29 ha , Approved Design Flow (gpd)
Installer �1.-/�4jVM/1� Ft/mNt°ft/
{
Designer: 1N.pn.a4 L'f4 • It.S Inspector:
The issuance of this permit shall not be construed as a guarantee that th : :te will function as designed.
No. rm /0 - /
y^J
FEE
COMMONWEALTH OF MASSACHUSETTS
1
Board o f Health, �/n r 4 1:4 krill- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade($) Abandon( ) an individual sewage disposal system
at ( j la Fctr:m3 Yw . Flb*'.Q
Disposal System Construction Permit No.
2oIa—/ dated
/
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All localdig'bns must be met.
Form 1255 Rev.srss.ue NOW co.cmrreanm,MA Date / V//t) Board of Health
No. 02W° 1
FEE AC0'ea
COMMONWEALTH OF jMASSACHUSETTS
Board of Health, Olne\IA.t9't-s p1t r MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fur a Permit to Construct( ) Repair( ) UpgradeV Abandon( ) - *Complete System O Individual Components
Type of Building SA/AL !1 lot Size 1 $0U sq.ft.
Dwelling-No.of Bedrooms s-Z - Garbage grinder( )
Other-Type of Building No.of persons y_Showers (/),Cafeteria
Other Fixtures
Design Flow (min.required) 22-0 gpd Calculated design flow 2-20 Design flow provided 330 gpd
Plan: Date I7 1 t11 ( C1 Nuu�mber of sheets 1 y Revision Date
Title 17 td4u1 C1 fyrrW-k. SQf�c Sc� �'l"`t
Description of Soil(s) I h ouim S .�
Soil Evaluator Form No. r 13 Name of Soil Evaluator IhO++WN
Lea. Date of Evaluation lo IS'09
DESCRIPTION OF REPAIRS OR ALTERATIONS
IP
L'
-he
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 Co I ti Feul,kS X.& ,
Owner's Name 3S.j is c/1,0 --t
Map/Parcel#
�+
Address ( pa fl(itd(.�ai/\G,4
Lot#
Telephone# S-gO -_g3-6
Installers Name
Designer's Name j/, Qom _
W
Address
Address/64 ��,�n -
Telephone#
Telephone# — — 3
Type of Building SA/AL !1 lot Size 1 $0U sq.ft.
Dwelling-No.of Bedrooms s-Z - Garbage grinder( )
Other-Type of Building No.of persons y_Showers (/),Cafeteria
Other Fixtures
Design Flow (min.required) 22-0 gpd Calculated design flow 2-20 Design flow provided 330 gpd
Plan: Date I7 1 t11 ( C1 Nuu�mber of sheets 1 y Revision Date
Title 17 td4u1 C1 fyrrW-k. SQf�c Sc� �'l"`t
Description of Soil(s) I h ouim S .�
Soil Evaluator Form No. r 13 Name of Soil Evaluator IhO++WN
Lea. Date of Evaluation lo IS'09
DESCRIPTION OF REPAIRS OR ALTERATIONS
IP
L'
-he
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
No.
COMMONWEALTTI OF MASSACHUSETTS
' .) . . ropll Ma
Board of Health,
CERTIFICATE OF COMPLIANCE
FEE
Description of Work: ❑Individual Component(s) *Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded (i),Abandoned ( )
hv. T.v,07,ay ( [W.
at 1 Ned'„ 2c-A
has been installed in accordance with the provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-buil
application No. i7t('I" - I dated P7ly! oi . Approved Design Flow i SO (gpd)
Installer T iin^ 'AS Wr.n » a Yc.
Designer: 1 ^ i . Inspector:Dau( 71.r,t !-rI4 Date: Y- 1 - '0
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, t\ )n r
DISPOSAL SYSTEM CONSTRUCTION PERMIT
PI
relating to
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(si) Abandon( ) an individual sewage disposal system
as described in the application for
at
:
Disposal System Construction Permit No. dated
Provided Construction shall be completed within three years of the date of this permit. All local gnndidons must be met.
Fon 1255 P ..5/96 AM.SWNm co.Cnaetwn.vA Date -A Board of Health -