Lot 4 Septic Appication & Permit Ni 1043
COMMONWEALTH OE MASSACHUSETTS
Board of Health
FFF?/CO
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - X.Complete System Si Individual Components
Type of Building r l L
4
Dwelling-No.of Bedrooms
Other-Type of Building
Other Fixtures
Design Flow(min, required)
Plan: Date t0 ' L `03
Title PriCs' C
.. •
Lot size .a Ac vr-ft
Garbage grinder PC
No.of persons Showers H-ta_xa^c^cie( )
440 gpd Calculated design flow 6490
Number of sheets
rrACe. c _Y. 0 (JESKM
Design flow provided 9,30 gpd
Revision Date
Description of Soil(s) Ste+ P-A•J f`�( L €`/Pr P017-0‘�
Soil Evaluator Form No. Name of Soil Etaluamr 1.nN?(.'.NV S
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Fink
ion (p F-0I
The undersigned agrees to install the above described Individual Sewage Disposal System in accord. f. w' TITLE 5 and
t
/further agrees to not t ace We sysm pemtiov until a Cerjjf%ate of Compliance has been issu- -alth.
Signed Date to -i'7i-03
Inspections
le-13
COMMONWEALTH OF MASSACIIUSETIS
Board of Health, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded (),Abandoned ( )
by:
FEE
at
has been installed in accordance with the provisions of 310 CM 15.00 (fide 5) and the approved design plan
application No. dated . Approved Design Flow (gpd)
Installer
built plans relating to
Designer Inspector: Date.
The issuance of this permit shall not be construed as a ar=^'--_-"'^ ill function as designed. ���
Locution pu Nrr-ly pR%VS"
Owners Nan e 'TCjl O CC LLAA.P1
Map/Parcel#
-�
Address , z /, g0 -- �,pl lj/a i tVAI
Telephone# 4-t3) 5.✓l - 6001
Lurk '}
I Installer's Name 4r�lte t-'w._. l to!JS
Designer's Narne--
nn
C , J*Ls R
Address 'i ---� k1 r-IAw�AJ
J S S HAtn filch) RO - P
Address'/D tAaa,r&rt/E en -�GJNa.r � lJ
Telephone# 4t-i) 52_,-7 - 0 00 I
_
Telephone# f�-r 3) sa✓l - Ddq 1
Type of Building r l L
4
Dwelling-No.of Bedrooms
Other-Type of Building
Other Fixtures
Design Flow(min, required)
Plan: Date t0 ' L `03
Title PriCs' C
.. •
Lot size .a Ac vr-ft
Garbage grinder PC
No.of persons Showers H-ta_xa^c^cie( )
440 gpd Calculated design flow 6490
Number of sheets
rrACe. c _Y. 0 (JESKM
Design flow provided 9,30 gpd
Revision Date
Description of Soil(s) Ste+ P-A•J f`�( L €`/Pr P017-0‘�
Soil Evaluator Form No. Name of Soil Etaluamr 1.nN?(.'.NV S
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Fink
ion (p F-0I
The undersigned agrees to install the above described Individual Sewage Disposal System in accord. f. w' TITLE 5 and
t
/further agrees to not t ace We sysm pemtiov until a Cerjjf%ate of Compliance has been issu- -alth.
Signed Date to -i'7i-03
Inspections
le-13
COMMONWEALTH OF MASSACIIUSETIS
Board of Health, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded (),Abandoned ( )
by:
FEE
at
has been installed in accordance with the provisions of 310 CM 15.00 (fide 5) and the approved design plan
application No. dated . Approved Design Flow (gpd)
Installer
built plans relating to
Designer Inspector: Date.
The issuance of this permit shall not be construed as a ar=^'--_-"'^ ill function as designed. ���
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
FEE../._.7t CC
....BOARD OF�HEALTH
�.(t�. OF_...1 ,lCG rf.(L7'I}!?i:L)j
Andiratinn-tor flttlpusal 3lnrk5 Qnuntntrtintt Prrntit
Application is hereby made for a Permit to Construct (✓ ) or Repair ( ) an lndi.idual Sewage Disposal
System at:
unit_“ ov{
h , kkS &
L{
or DA ]o.
Address
Address
Size I.ot Sq. feet
Type of Dwelling—n
Expansion Attic ( ) Garbage Grinder (��}
Otelri—Type of Bedrooms 1r howers Cafeteria )
Other—Type of Building .. No. of prouns Showers ( ) -- (
Other t tres O Q gallon
Design Flow �_ l gallons per pet-son per day. Total daily flow
Septic 'l:n6 Liquid c me itv�..y?.O4-':illons qq l.gngth Width Demeter Depth. sq. ft.
Disposal Trench- No Width_.yzs(1 Total Length—�D( Total leaching area /P
Seepage Pit No Diameter Depth below cadet Total leaching are sq. ft
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I minutes per inch Depth of Test Pit-5ele1 Depth to ground teats-
minutes er inch De th of Test Pith 'IF ` Depth to ground water
Test Pit Nat per Depth
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 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.
S I
e _ _ .� I hevuXL.NS
w! iwt. ��
Application Approved By y v(? 1 oal L%7
Application Disapproved for the following reasons'
Permit No 7.;-5
Issued
Oar
',:w,._ li,_1.5:.7.
Date