256 Applications & Permits COMMONWEALTH OFD LASS IIUSETTS
Board of Health, I Adyse
FEE s..2":1)
fJ4/1 d0
APPLICATION FOR DISPOSAL SYST I CONSTRUCTION PERMIT
don for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑Complete System)(Individual Components
f Building
Lot Size sq.f.
B
Garbage grinder( )
tg-Ne of Bedrooms of
.Type of Building No.of persons Showers( ).Cafeteria( )
Fixtures
Flow(min.required) gpd Calculated design flow Design flow provided
Date Number of sheets Revision Date
gpd
ption of Soil(s)
:aluator Form No.
Name of Soil Evaluator
RIPTION OF REP ORAI.TERA]'IONS
Date of Evaluation
t
ndersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
er agrees tom place syste in operation until a Certificate ofGCompliance has been issued by the Board of Health.
Date Ihloct
ctions
ion LS— SNt✓E H114_ FO'
Owner's Name ,ki etf7')c3 (-,S&^A_1
,
'Parcel# P14917 b Z [OT I
Address Z.1 6 JI L✓ -J 5,-- it
Telephone#
/
se y.s''j 9
Iler's Name
D 0 i f^l bj• ''"t /4-v"r)
Designer's Name
f Cr/An' C, 4
ess
/knq A TIV p. ,trr
Address ¶
a (,e„„4,,,, Li
t 'Ta wl
)hone#
Telephone#
f Building
Lot Size sq.f.
B
Garbage grinder( )
tg-Ne of Bedrooms of
.Type of Building No.of persons Showers( ).Cafeteria( )
Fixtures
Flow(min.required) gpd Calculated design flow Design flow provided
Date Number of sheets Revision Date
gpd
ption of Soil(s)
:aluator Form No.
Name of Soil Evaluator
RIPTION OF REP ORAI.TERA]'IONS
Date of Evaluation
t
ndersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
er agrees tom place syste in operation until a Certificate ofGCompliance has been issued by the Board of Health.
Date Ihloct
ctions
FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health.
CERTIFICATE OF COMPLIANCEe1r
ion of Work: U Individual Component(s) U Complete System
lrsigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ).Upgraded ( ),Abandoned ( )
n installed in accordance with the provisions
ion No. , dated
of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
. Approved Design Flow (gpd)
In
Spector.
a guarantee that the system will function as designed.
aance of this permit shall not he construed as
fission is hereby gran
Date: 48 ilogc-7
COMMONWEALTH OF MASSACHUSETTS
Board of Health, , ` A.
DISPOSAL SYSTEM CONS IR CTION PERMIT
d to; Cot stcact( ) Repair pgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
FEE 9
ref 61/4/it.'�.
t
:sal System Construction ermit NoJOt —(o dated (/f( /rO 3
ded: Construction shall be completed within three years of the date of this p
is aev.5R6 AM.SWARM)LAaAe!!wn.MIA
Date/h/o 0 Board of Health
All local condido
must be met.
r
THE COMMONWEALTH OF MASSACHUSETTS
Ena..:
BOARD OF HEALTH :.:' ,/,
Tow » of Ill.n_rt4t cl,sAA FAQ..vl e0)
1ppiiratiou for 3ispusttl lit arks (nnnsturtiun Per
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individati, S e Dis
.5. lv.m.S -e--.o iii. Sr
oration-Address IN �t `
{'� .....2 C'ti..sr MI\oNr 1R ..4 sle-atl.t,�.t: 14 A
..4��. Address J.
Installer Address
i of Building Size Lot3t(2 1.2t 3.....Sq. feet
Expansion Attic ( ) Garbage Grinder (X )
Otheri—Type of Bedrooms 5 Pa
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures U X 1. -• %15 gallons
gn Flow $...5 gallons per person per day. Total daily flow :550 S gal
tic Tank—Liquid capacity./$045 gallons Length...APs.Z_- Width.-S ^ Diameter Deptl3 . . 4Sass Sass sisal Trench—No. 3_.._... Width._.2' Total Length 7$ - Total leaching area_ Li 50 sq ft
cage Pit No Diameter Depth below inlet Total leaching area.1.5Q-...sq. ft. oa\3c,
er Distribution box (x ) Dosing tank ( ) / /
colation Test Results Performed by �1^-rm0 C e-`+ t.y.tere.x-.- Date y(---'.t o J -s 7.
Test Pit No. 1 $._.minutes per inch Depth of Test Pit 7 Depth to ground water SA
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
cription of Soil._Scee °... 'C"'O� °+
ture of Repairs or Alterations—Answer when applicable
reemenc
The undersigned agrees to install the aforedesaibed Individual Sewage Disposal System in accordance with
provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
tern in operation until a Certificate of Compliant- has been issued by- boaf'd of h alth. 50
iplication Approved By - - -®- Slit I/20
iplication Disapproved for the following reasons: -- -- - - - - - - -'
Permit No.
Dale
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C. i{ OF Noc-k 0-yvppl1
{3..oh
h.Irrtiflratr of QInmplianrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( A ) or Repaired ( )
ELL OmAsrA
'or#// SrintsrER At 90 / yoRTfi4MPr"i n
�e. : KFV/N on's)
leen installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
t
pplication for Disposal Works Construction Permit No. 7—?O da 9/n/..90
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS IARANTEE THAT T
TEM WILL FUNCTION SATISFACTORY.
/0!S/f0
'E
Inspector-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r 1 l
flis}Tnsal
Permission is hereby granted
:onstrpct (Z( ) or Repair ( ) an Individual Sewage Disposal System
fo
�r•
n;KE Qinnstruttinn Pa Et
FEE
r*,,1 9?)
street
town on the application for Disposal Works Construction Permit No Dated
Board of Health
CE
1 1255 HOBBS & WARREN. INC.. PUBLISHERS