502 Title 5 Application/Permits 1996 Inspection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: .5-02. ti ho r rh R'+°(
Owner: #1 a, rt 5vN,n,di
Date of Inspection: 2/2 7 7 9f✓
BI SYSTEM CONDITIONALLY PASSES (continued/
_ Sewage badsup or breakout or high static water level observed in the distribution box is due n if wki n al t he
PIPS/ or due to a broken, settled or uneven distribution box. The system will pass inspection
of Health).
_ broken pipets) are replaced
_ obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspectton if with approval of the Board of Health)-.
_ broken pipets/ are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) WHICH H WILL PROTECT THE PUBLIC HEALTH AND SAFFETY AND THE ENVIRONMENT:NOT FUNCTIONING IN A MANNER
VIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) THE SYSTEM LIS FAIL UNLESS THE BOARD OF FUNCTIONING IN A MANNNERETHAT PUBLIC
E PUBLIC HEALTH AND SAFETY AND TH�RMINES THAT
EN\'IRON 1E\T.
•,,te,I m, a .evu\ idn, diw „,1. [hall. ss s; �,.and s\%;:h.0 :CC (cc: to c 3_..c= s.a.cr S000!”, or ..._ ._
surface water supply
The system ha a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and sod absorption system and is less than 100 feet but 50 feet or more from a private watt.
supply well, unless a well water analysis for coliforrn bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
DI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be raced to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due roan overloaded or dogged SAS or cesspool.
_
Discharge or ponding of effluent to the surface of the ground or surface wren due to an overloaded or clogged SAS or
cesspool.
2
Irevasea 5/15/95)
William F.Weld
••emc,
: ECU
David B.Sbuh•
meenmei.
Commonweotth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Address of Owner: 5 C i N Fe r 11" R .4
(If different)
Property Address: 5o a »/ /-q rm S R ca
Date of Inspection: 2/27 /%e
Name of Inspector: ft /J.eS
Company Name, Address nd Telephone Number: r,Le; En/Y✓ Inc.
4'i P IA44,. ,cd
CERTIFICATION STATEMENT 4w,Ail /1A-
,
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the ume of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems- The system.
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fads
Inspector's Signature:
Date: 7421 / 76
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty 001 days of completing this
inspection. If the system is a shared system or has a design flow of 10.000 god or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent Io the system owner and copies sent to the buyer, if applicable and the appro■ing authority.
INSPECTION SUMMARY:
Check A. B, C. or D
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
Bl SYSTEM CONDITIONALLY PASSES:
_ One or mole system components need to be'enlaced or ngairW. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If'not determined', explain why not)
The septic tank is metal, toadied, structurally unsound, shows substantial filtration or meditation, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 1115/951
1
One Winter Street • Boston,Ms•uehuwW 02103 • FAX(6173 53610•9 • T•Mphon•(617)a2-SSW
0 sense a aser Pepe.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Propeccr Adds: 5e2 ti ran rhs Rn.d
Owner. hit.
Date of Inspection:
a-( a 14Ct
DI SYSTEM FAILS(continued):
hilS Static liquid level n the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6' below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipets).
Numbe oft mes p roped_.
W0 Any pomon of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply
t Any portion of a cesspool or privy is within a Zone I of a public well.
NJ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
NP Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. II the well has been analyzed to be acceptable, attach copy of well water analysis for
coli(orm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS
The following criteria apply to large systems in addition to the criteria above:
The design flow of system a 10.000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist.
the system is within 400 feet of a surface drinking water supply
the system n within 200 feet of a tributary to a surface drinking water supply
_ the systnm is lanceted in a nitrogen sensitive area(Interim Wellhead Protection Area IIK'PAI or a mapped
Zone ll of a
public water supply well
The owner or operator of any such system shall bnng the system and facility into full compliance itho the�fndf treatment program
requirements of 314 CMR 5.00 and 600 Please consult the loot regional office of the Oepartme
(revised ensnm
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
5 Z N iarar� �Cc.-d
Li 27/7L.
Check if the following have been done:
w1Y SPumping information was requested of the owner, occupant, and Board of Health
None of the system components have been pumped for at least two weeks and the system has been receiving rmaaiow rates
recently
that period. Large volumes of water have not been introduced into the system cently or as pa of this
firr
As built plans have been obtained and examined. Note if they are not available with N/A.
ZThe facility or dwelling was inspected for signs of sewage back-up.
hiL The system does not receive non-sanitary or industrial waste flow
1The site was inspected for signs of breakout.
m-All system components, excluding the Sail Absorption System, have been located on the site.
Ite6The septic tank manholes were uncovered. opened, and the interior of the septic tank was inspected for condition of baffles or
I tees, material of construction, dimensions, depth of liquid, depth of sludge. depth of scum.
_The size and location of the Sail Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods
_The facility on cer ;and occupats. if ddfe't (TOM owned were provided with informaton on the proper maintenance of Sub-
Surface Disposal System.
(revised 1/15/95:
Property Address:
Owner:
Date of lr ection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Se z ti r---4 COI R 1
%Lc+: ltr Soh'.,,d}
2_/27 /4e
SEPTIC TANK:JgOU
(locate on site plan)
Depth below grade: 7" '
Material of construction: concrete metal FRP_mhedexplaln)
Dimensions: ie X S ' ( Y ci eda-i)
Sludge depth. y—l."
Distance from top of sludge to bottom of outlet tee or baffle: 2.9
Scum thickness: 2-3
Distance from top of scum to top of outlet tee or baffle: 6 t
Distance from bottom of scum to bottom of outlet tee or baffle: 16
Corments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP:_
(locate an site plan)
Depth below grade._
Material of construction: _concrete metal FRP_othenexplaml
Dimensions.
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
D•'.•a^•e rip^ boric.", n.nom m aln.e• le^ a' oar t
Comments
(recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
tmegnry, evidence of leakage etc
(revised /15/55 6
4/4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: SC Z ti( Y4c M S
Owner: haf, l7n S. art
Date of Inspection: 2/2- //go
RESIDENTIAL:
Design flow: gallons
Number of bedrooms: 3
Number of current residents:..
Garbage grinder(yes or no):_ph)
Laundry connected to system (yes or nol: S.i e}
Seasonal use(yes or nol.Jyl7
Water meter readings, if available: tr// /OP/
FLOW CONDITIONS
W €/.E t(
Last date of occupancy
COMMERCIALS NDUSTRI AL:
Type of establishment:
Design flow:__gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or nol_
Water meter readings, if available:
Last date of occupancy.
OTHER: (Describe,
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informauona q l�
System pumped as pan of inspection Wes or noI IJLx
If ye. volume pumped gallon• 'T
Reason for pumping
TYPE OFiSYSTFM
Septic tank/distribution bor/soil absorption system
_ Single cesspool
Overflow cesspool
Privy
_
Shared system (yes or no) (if yes,attach previous inspection records, if any)
Other (explain)
APPROXIMATE ACE of all componentS, date installed (if known)and source of information:
/967
Sewage odors detected when arriving at the site: (yes or no)
(revised 5/15/951
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Cc Z N r g r m>
Owner: )14r lyh
Date of Inspection: l Sc .y,; e t
2—( 2-7/7Q
SOIL ABSORPTION SYSTEM(SAS):_
(locate on sire plan, if possible; excavation not required, but may be approximated by non-innusive methods)
K,:
If not determined to be pretend explain:
Type:
leaching pits, number: ✓ y/
leaching chambers, numbed_
leaching galleries, number:_
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegeupon,etc)
CESSPOOLS:
(locate on site plan(
Number and configuration'
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool.
Materials of construction:
IndLcaLOn of grcund..ate-
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of sod, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of mnstruaion: Dimensions:
Depth of solids:
Comments: (note co condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc)
(revised Vvs/es) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: $e Qs-
Owner. Nag., (7w 5-h+.:dn
Date of Inspection
z� 2- 1J9[.
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal _FRP_other(explaml
Dimensions.
Capacity: gallons
Design flow: sallons/dap
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: Y
(locate on site plain
Depth of liquid level above outlet invert
Comments
(note if level and f {gb4M t t CaOlAor P of J rxca•L%er. golden"h of Igakage A into`o.:Hof boS etc.)
e lac
PUMP CHAMBER:_
(locate an site plan)
Pumps in working order(Yes or no)_
Comments: etc.)
(note condition of pump charnber, condition of pumps and appurtenances c
7
(revved 0/15/951
Property Address: .SCE r".
Owner. , //in
Date of Inpection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
2/21/76
re,rMS Kc..;ol
Sci)a.df
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include neierenoss landmvks or benchmarks
ude ties to at least two permanent
all wells within 100'
ISeCial.
µC05 E
DEPTH TO GROUNDWATER
Depth to groundwater. L ' Ji.F— �/ { coo /f le M
method of determination or approximation: Q 9Yl 0
rrL'nd ,`'Ti
isafar'
9
Inv sled •/lS/951
HERE APPLICABLE
CHECK OR FILL IN
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD On
APpliratinn for finpusal marks Otanstrurtinn Vrrmit
Application is hereby made for a Permit to Construct ( or Repair
System at:
_....f'
ail L
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench--No
an Individual Sewage Disposal
No
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
of persons Showers ( ) — Cafeteria ( )
No
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter
Width Total Length
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing�°j�
Percolation Test Resu s e Performed by_LFJr°°'° --�.a.r f
Test Pit No. 1... . ...minutes per inch Depth "Test Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
Depth
Total leaching area sq. ft.
/�
Total leaching area sq. ft.
6a"i -Date 6- /`; /'761
Depth to ground water_
Depth to ground water's �'mn
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
e
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI 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
Signed
Application Approved By
Application Disapproved for the following reasons•
Permit No
Date
Date
Date
Issued
Date
by
at
has been installed in accordance with the provisions of Article XI 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.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
f rrtifirate of tanmplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF _. .
flispnsal ri nth!' Q nnstrurtina jrrmit
FEE
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No Street
as shown on the application for Disposal Works Construction Permit No
Dated
DATE _. . ..
FORM 1 255 HOBBS a WARREN. I NC.. PUBLISHERS
Board of Health
IECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
FEE
_ BOARD OF H LTH
OF
Application for fltopcoat I.H into Qlnnotrurttnn j rrmit
Application is hereby made for a Permit to Construct ( or Repair
Syst®a at:
4i
an Individual Sewage Disposal
Lot
Address
Installer Address
Type of Building 1 Size Lot Sq. feet
Dwelling—No. of Bedrooms "L Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow 1.0 gallons
Septic Tank—Liquid capacity/I/a...gallons
Disposal Trench—No Width
Seepage Pit No Diameter
per person per day. Total daily flow 4'G d gallons.
Length Width Diameter Depth
Total Length Total leaching area Depth
Total ft.
Depth below inlet ' Total leaching area sq. ft.
Other Distribution box ( ) Dosing,( n' �� •
Percolation Test Results Performed by.
minutes Depth f Depth ground Pit No. i..F...SC7 per inch D th est 'it D pth to ground water m "
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
/ ,at= Z
Description of Soil ��� ����-�''
'^'0— t ate..C/3b/70
i
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 been issued by the board of health
Signed
Application Approved By
Application Disapproved for the following reasons'
Permit No
Date
Date
Date
Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
°Irrti&atr of Otmnolianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of Article XI 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.
DATE Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ..
Elin}mnal
nrkn tannntrurtiun j rrmit
FEE
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No Street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
WORM 1255 HOSES Si WARREN. INC.. PUBLISHERS
CHECK UK 1(11.L IN
No.....gj.0L
THE COMMONWEALTH OF MASSACHUSETTS
Faa_�t/S..�%r��...
BOARD OF HEALTH
OFt� y
?ppliratinn for Disposal Works Cnnnstrnrtinn jrrmit
Application is hereby made for a Permit to Construct (L') or Repair ( ) an Individual Sewage Disposal
System at• y L/J
f f Te2.a2_..se.Kr `wnaid"'`'K"e"
Lac Non-Address" L�
or Lot No.
cll,�yJfa'"u
Address
Ire taller!/�/ Address
Size Lot Sq. feet
Type of Building
Expansion Attic ( ) Garbage Grinder ( )
Dwelling Type No. of Bedrooms p Showers — Cafeteria ( )
Other—Type of Building No. of persons ( )
Other fixtures gallons
Design Flow gallons per person per day. Total daily flow
Septic Tank—Liquid capacityA zngallons Length Width / Diameter Depth
Disposal Trench—No Width_So I Total Length {..LI Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area a.47 sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
minutes er inch Depth of Test Pit Depth to ground water
Test Pit No. I P ground water to Depth Test Pit No. 2 minutes per inch Depth of Test Pit De p g
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:ITIL 5 of the State Sanitary Co.' —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b= iss c b the Board ealth.
Sign
Application Approved By
Application Disapproved for the following reasons-
Permit No
9Ja
Issued..
i
7
4
4
No....;44
THE COMMONWEALTH OF MASSACHUSETTS
ej BOARD OF HEALTH
OF /'/ T:.77 51/t
Appliratinu for Binomial illurkn Cnnnntrurtiou 'rrmtt
Application is hereby made for a Permit to Construct (✓ ) or Repair ( ) an Individual Sewage Disposal
System at:
Location qA ,ddress p_ / ,
.<.a..: ...v.w..i�..0. t!..
L...._......
J Owner
Installer
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacitf422y.gallons l;ength Width / Diameter Depth_______..
Disposal Trench--No......_........._.. Width..,:a.t Total Length `f L Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area.2-OP 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 minutes per inch Depth of Test Pit Depth to ground water
or Lot No.
Address
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
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':ITL' 5 of the State Sanitary Code,-The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss» by the card health.
7 a:r-{
Signed-..�----fr
Application Approved By '•
Application Disapproved for the following reasons'
iTzfidy
Permit No.. (//9---
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
hirrtifiratr of flluniplianrr /
THIS.IS TO,CERTIFY,,That the Individual Sewage Disposal System constructed l r Repaired ( )
: c t :' .c e`-G
by i_
Installer
at / al -{s C i L.da—110.1m.s 1'!/has been Installed in accordance with the provisions of TiTiah j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No 7/-71-
dated-.'. .kit( X-/-7 71.7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. q'�: / 2/-
,, �
DATE ,:_that f
inspector. }.!I-r
THE COMMONWEALTH OF MASSACHUSETTS
}} BOARD OF HEALTH
.!
. I 7itta t J .. OF s / `F 'T-/.` rt
No....fi.,n.
7Tpp
poem ilnrka Oionstrurtian lrrmit
Permission iyhereby granted ti,/:.-s`— -
to Construct (V) or Repair ( ) an Individual Sewage Disposal System
at No sht.C-. - F _acid(
as shown on the application for Disposal Works Construction Permrt Dated 1?s L ix�
/!^!
l�
L.2 T age n-( fic`tt
- - - ' Board of Rea]tI (.
DATE
FORM 1255 HOBBS 8 WARREN. INC.. PUBLISHERS
No. J1'15".
THE COMMONWEALTH OF MASSACHUSETTS
Aioizn4a+/mProA) MASSACHUSETTS
Fr f
1pplictttinn for pispoinit System C[Cnnstrnctinn Permit
Application is hereby made for a Permit to Construct( )o Repair O )an On-site Sewage Disposal System at:
Location Adel ess or Let Nn. l n
.5-0z 4
0z ACTW /-Gems .P
h.ale ,Nene.Addree an Te No
Owner\Name,Address and Tel No I 1
RIMIZA )Name, nuv r rg c AZJ�iaSZ o2
Abew AAKMS Ita
pp::MS.F.umtor creek e%L3 S84 A161
A-trgij`i12AA3 sdagtrNo. Iuc rth& Tit
ST efitLlev mass
J/3
a6-2 112A
Type of Building:
Dwelling No.of Bedrooms
Other Type of Building No per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 5.1)4
Plan Date 1917.4(515- N
Tide
Garbage Grinder(44-4
gallons per day. Calculated daily flow JAS
Description of Soil
gallons
Nature of Repairs or Alterations(Answer when applicable
Date last inspected'
Agreement;
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board of Health.
Signed II _ a 't'_ ___•-
Appl]cation Approved by 7/•�'—+�I��e rat<
Application Disapproved for the following rea
1 r/4C
a-
Permit No
Date Issued
THE��COpIMMONWEALTH OF MASSACHUSETTS
IVOnrenfi10TD Ai MASSACHUSETTS
Certificate of Compliance
HIS fS TO CERTIFY.thatt e Sn-s. Sewage Disposal System installed( )or repaired/replaced(Y)on
r!l3/9(s by _ e
at _C C 1 AT 0,e IN Tl E n C 'n has been/constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. D ' - -S dated
C / -1 I 14 C Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate I 70.1 eon con, rued as a guarantee that he system will function as designed.This
Certificate expires on _
DATE
No
Inspector
)°k 2Adfs-
THE FOMMONW EALTH OF MASSACHUSETTS
4 Krylgnr#-WA) MASSACHUSETTS Fea t
!leanest System Construction permit
Permission'A hereby granted to d. Crh NA A d1 r kcv't-
to construct( )or repair(N an On-site Sewage System located at -CO2 i0 /flf?mS /9r2
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction o3ust be completed wuhinthree years of the dote below. 0
DATE El-ENE. T1// I 1115 C Approved by
1541%t✓6-a-r(_
No C� /
FEE/1)19S�
THE COMMONWEALTH OF MASSACHUSETTS
J. STH/aWi$7D.v MASSACHUSETTS
c&ppliratfiart far !iSpuSa{ !System Curt trttrtian Ermit
Application is hereby made for a Permit to Construct ( ) or Repair(X)
an On-site Sewage Dispo al System at:
I ocation Address or Lot No.
v' O2 A cheni 4Em ,
Owner's Name,&pC dress and Id/r,N�o. l
$7 ica3a; dmt4T 4cw4c.e AntTt1Y SO2
Abell Adams Ro Aloemiteru far)mass
/IU S.wntor' a+eerc `PS S86 816'1
Installer's Name.Address,an Tel.No_
TSi M
��sr/ �me ar r dit /u
C t(.46
87" 1R41ayly 01455
tin 1461 122A
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder(4
Other Type of Building No per Persons
Other Fixtures
Showers
Cafeteria
Design Flow 5.04 gallons per day.
Plan Date /124110
Title t it/oC /�Te S'
Description of Soil
Calculated daily flow ins
ber of sheets Revision Dat
1iI
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board of Health.
Signed
Application Approved by
Application Disapproved for the following
Arne —Fen
win reas.ns
ate
ii(it/y e-
zjOi14s
Permit No.
Date Issued
No "21
THE
,, ICOMMONWEALTH OF MASSACHUSETTS
No�2TNAnn(rnAi ,MASSACHUSETTS
frpltcattxtt for pt$pusat SgstEm QlDnztrttrtion Permit
Application is hereby made for a Permit to Construct( ) or Repair(K) an On-site Sewage Disposal System at:
n,W/CvO *K ld/[p n^„✓QrAv >n2 owner's Same,Andress and Tel,No
Fbc: F
vgins /24 Ai oe4l4,kINrdJ 71(A55
M5,S1Im/Dr• £X Ck 1i -S% Fs-76.7
iFgiguim Fi d re. ss Txel.lCN.
l46 7avalk.
St y,'L4T,I3./ ,iI4ss
t//9 1167 1)2%
Location Address or t_et No.
SO2 Abate <1en/5
InRZlfers Name.Address.and,Tel No.
—r
Type of Building:
Dwelling No. of Bedrooms i Garbage Grinder(4-)
per Type of Building
No. er Persons Showers ( ) Cafeteria( )
Other Fixtures
Design Flow
Sn nl gallons per day. Calculated daily flow In gallons.
Plan Date 9/7/74C Nu Aber of sheets / Revision Date
Title/1Cs/,xJ/CCSspncSvs1F 1 /-Cle AI.se1ownr PAh✓r+rCY )2AJAi(�i5Rt ti/o(An MA
Description of Soil . �r n)U (ndnl ,nI3f cm /r(7..t nAl nC/<Ai yq,,
'-k- /ce-rv, VAl•J HMi/A(
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected'
Agreen4nt:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board of Health.
Signed
' Application Approved by
Application Disapproved for the following reasbns
Permit No.
Date Issued