422 Applications & Permits b) HE C+MMONW ALTH •F MASSACHUSETTS 028— /
' e MASSACHUSETTS
r'u'V 1 q `°c' VSP(iftrate of Qloaililiariwe �/
THIS IS TO CERTIFY, th he O; site . ag5 a i`r, 1 System installed( )or repaired replac on `�///_
by. { V for �.Q Pnhe V
t has been constructed in
ccordance with the provisions of Title 5 and the for Disposa System Construction Permit No ? _p?_ dated
•i — -'7.'o a-- Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be co as a guarantee that the syst will function as designed. This
:ertificate expires n �- -1'7 0
/ I
)ATE S X01 Inspector ��
: -1
No..oa.:i...A FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-'
r,
Application fur 3]ispusal I! arks Chunsfrurtiuu ljrrmif
Application is hereby made for a Permit to Construct (• ) or Repair ( ) an Individual Sewage Dispo
System at:
:LS.o4 :-::{ w .i •., •
L atiaf•Address or Lot No.
Owner t Address
..1 -. _` C- llera;.L.�t>•
rq Installer Address
U• Type of Building Size Lot Sq. f
.a Dwelling-No. of Bedrooms -'ti Expansion Attic ( ) Garbage Grinder
GL Other—Type of Building No. of persons Showers ( ) — Cafeteria
Us Other fixtures
6
W Design Flow 11R,___...gallons per person per day. Total daily flow O J gallo
W Septic Tank—Liquid capacity..4:1 0 gallons Length Width Diameter Depth
Disposal Trench-No. Width .1.4.; Total Length se '' Total leaching area 1 sq.
▪ Seepage Pit No Diameter Depth below inlet Total leaching area sq.
z Other Distribution box ( ) Dosing tank ( )
.7 Percolation Test Results Performed by Date
,] Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
W Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
W
O Description of Soil
B1
W
UNature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance w
the provisions of Article XI of the State Sanitary Code-- The undersigned further agrees not to place the system
operation until a Certificate of Compliance has been issued by the board of health. A
Signed __ ._.- s..... ia. Wit,
' Date
Application Approved By • ' l - L:._sJ S U•1
•
Date
Application Disapproved for the following reasons
Date
Permit No.....d:...L..1 Issued .-t
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,
OF / f
Tirtifiratt nt
'HIS IS TO CERTIFY, TV the Individual Selvage Disposal System constructed (11 )e or Repaired (
• Installer
-en installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
anon for Disposal Works Construction Permit No 7 dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A CiLUARANTEE THAT THE
"EIVI WILL FUNCTION SATISFACTORY.
E • 1.1 I Inspector tecr)
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF L
Eligposal Il urks Tottritrurtitan litrutit
Permission is,,kereby granted ....
onstruct ( n or Repair ( ) an Individual Sewage Disposal System
Street
own on the application for Disposal Works Construction Permit No
Dated 'iiievas :14-1
FEE
Board of H41;
PE L:es cz..0
A 1255 HOBBS IL WARREN. INC PUBLISHERS
-07—
THE COMMONWEALTH OF ASSACHU5ETT5
A/49./e-7511.9in,e-rd .MASSACHUSETTS
cAppticnfian far !ispnsa1 (5gsfem Znnsfrurtinn Permit
ration is hereby made for a Permit to Construct ( ) or Repair Lf1'an On-site Sewage Disposal System at:
Owners Name.Addres.s}ud Tel
ES 7/%nnP2 a Ey/Lf/62L/
4J4 S/tV 37 7€
N 282.3
70.t/
her,Name,Address,and TeI.No. Designers A ress ANooA,PE
A VA Lfr Ca",57R✓!�"ezi't) 99 $'LEa✓OAC!- Sr
Na.er O.Y+n"7-V4 ) $fl-3779 a/7D..7j /*hi S27-T29O
of Building: 3
Dwelling No. of Bedrooms No per Persons Showers( ) Cafeteria( )
Other Type of Building P
Other Fixtures
;n Flow
3 by _ gallons per day. Calculated daily flow 3 30 gallons.
Date
/—/q —dZ Number of sheets / Revision Date
Title DuJ* gt Zp02— oo/
:ription of Soil
on Address or nor No.
72
5-Y4V63?e"D2lem3D
Garbage Grinder(.149
itisdftra
/ r AN BONY r�\
ire of Repairs or Alterations(Answer when applicable) 7AN S a CVs ����
-L - E JS . Sc7�7/!
'7y -; / DO — �. M'S - Fi Oktiiiielefitit
c last inspected'. V � ,
rte/
eement
The undersigned agrees to ensure the construction and maintenance of the afore r abed on-s sewage disposal
em in accordance with the provisions of Title 5 of the Environmental Code and not to ce the system in operation until a
tificate of Compliance has been iss ed by this and of"Heal"
Signed an" 7 24.c.i'
Date
plication Approved by
plication Disapproved for the following reasons
Date
f-
Date Issued
Permit No.
THE C MMONWF,.ALTH OF MASSACHUSETTS
ifi /0471 /-Y/N- , MASSACHUSETTS
Certificate of Compliance , ��
THIS IS TO CERTIFY th he Op-site ewage Disposal System installed( )or.repaire��pl replaced{Lv on
/ tti,LAt A VtC (',t%. for 7'Q z i ( °1
has been constructed in
at `�y a b -v t t dti �` � - _C�. dated
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No
.-7 - T. -7--C-7- . Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certifica^e shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on i c _
DATE
z �'_ Inspector f-T_T pLam-[ � --,-�
No
THE COMMONWEALTH OF MASSACHUSETTS
1/c//l/l uv 71"4' , MASSACHUSETTS
pispnsaL gstent GIunstructinn 3ertnit
FEE
Permission is hereby granted to . 1 -s r 1 4{7,2 c:
to construct( )or repair�)an On-site Sewage System located at y -��
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 must be completed within three years of the date below. (; L.t /c�
DATE r,-- G1 �'- Approved by G L
FOFM 1255 Pe v 3 95 P M SILKLN CO-BOSTON,MA