88 Septic Applications & Permits 6 Type of Building
Dwelling—No. of Bedrooms
`� Other—Type of Building No. of persons
, N020C-09
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a5--- OF AI kav a eS+A
1pplirntinn fur Dispnual Works Tnnstrnrtinn jrrmit
Application is hereby made fora Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: -,, /eg) ferric. zaM✓c,
04 'date.
mac... ..
���
or Lot No.
Expansion Attic
Address �t//
Size Lot /`Y A' Sq. feet
Garbage Grinder (1-4.
Showers ( ) — Cafeteria ( )
W Other fixtures 7d� gallons.
4 Design Flow .„948 gallons per person per day. Total daily flow P.1 �•rgallons Length Width Diameter Depth
a Septic l Tr nc Liquid capacity. . g Total Length Total leaching area sq. ft.
0..1
• Disposal Trench--N/o/.L Diameter Depth g
▪ Seepage Pit No PST Diameter Depth below inlet Total leaching area sq. ft.
z• Other Distribution box (q$77,,t/6.Dosing tagIc 9
'H Percolation Test Results minutes per by
LP Date
Test Pit No. 1 -minutes per inch Depth of Test Pit Depth to ground water
k, Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
0
Nature e of of Repairs or Alterations—Answer '6i hen applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
h provisions of:I'TI. 5 of the State Sanitary Code—The undersigned furtive agrees not to place the system in
oar of health
operation until a Certificate of Compliance has been=.ued by th
Signed-f°-
Application Approved By
Application Disapproved for the following reasons
eat
Permit No .?"0.6.-.09
Issued
Date
Date
DATE
No
Jet -0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H TH
BispOSttl rpOrk _n
to Construct ( or Repair ( an�
ual S age System :
emit
Permission is hereby granted. .-..
at No
as shown on the application`fdr Disposal Works Construction Penn
sl
DATE_,i:.Q_L(.
FORM 1255 HOBBS wPRREN. INC.. PUBLISHERS
Date•
!%i
of alth
o d of health
r ! THE COMMONWEALTH OF MASSACHUSETTS
74se -TN/9 4vF 7DA,d MASSACHUSETTS
FEE
■ppp1iratton fur !izpu9al $gatem Construction Permit
Application is hereby made for a Permit to Construct( ) or Repair fX)an On-site Sewage Disposal System at:
5L = 7 ?
Location Address or tot No.
p
BCC �f/��%"�� ��.
Owner's Name. Address and Tel.No.
o-AdieE Al . LAS66 ( LrriFMNw
. 6/a- w£ MGN Crte2 CT •
k EFN£ /LA! 6G:' ?5-2 —/9% 4--
Irmnller's Name,Address,and lal No. Designer's Name.Address and Tel.No. t Pt
M.S. Loom IS tX rAV/+TJ}" 3-Awe = A ej re Ar/�
YEW re 1 �7• .327-�j,3 99 tit erR.P.h/ et- =7 577-5280
E- A r-7-MA✓JL'�7Dd/• %h/i 3 EH 57i-/i4M.✓rz -t MA
Type of Building:
Dwelling No. of Bedrooms 3
Other Type of Building
Garbage Grinder Oct
No per Persons Showers( ) Cafeteria ( )
Other Fixtures
tures _
Design Flow i 4 gallons per day. Calculated daily flow 7•S gallons.
c frfro
,l%/A/4 A'2OCO -007
Plan
Date
Tie,
Number of sheets
Revision Date
Nature of Repairs o Alterations(Answer when applicable)._terg .9 r F Fr
L r-• rig "i7 H//•-7/-/ LEJ9 lit n-7
EY/57/n/eS /Soo .
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescr 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 isstu&by this Board of Health.
V n ( ^y r %. + Date Ci�j y/)(fit)
y/
Application Approved by jT`t- (rt��'�� Date
Application Disapproved for the following reasons
Permit No. Date Issued
' TH�E�gOMMONW,,A LTH OF MASSACHUSETTS
! �1—�r--�- , MASSACHUSETTS
Certificate of Compliance y�
Ty S TO CERTIF th the On-site Sewage Disposal System installlee ( ) or repaired/replace//Sr .on
c I 00 by I. J . �.:0//l1, for . Ion tef �'A6 OE i-C /i%: /114/V
at J ) (//4444-) /H'z h . has been constructed in
accordance wijtythe provisions of Tf(le 5 a9 the for Disposal System Construction Permit No. a 7- �`c� dated
'� r// lCJ . Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate NE shat not a construed as a guarantee that the system will function as designed. This
Certificate expires on ✓/ l -- ^ C
i s .4y '
DATE ��= a1�, /i �C Inspector )�"-c �� yr
N. 7 /II /,
THE COMMONWEALTH OF MASSACHUSETTS '
L > :
No. AA i7/'t^ , MASSACHUSETTS FEE -
!isposul $gstem Construction Permit
Permission is hereby granted to ±,• .e�..- - 1
to construct ( ) or repair(L 4an On-site Sewage System located at t-�.-., d. �4y Fy/
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. ���
DATE i / r-.! Approved by %/ i--- — ft"
FORM'255 Rev 3'95 AM.SULKIN CO-BCS ON.MA