15 Septic Application Permit & Compliance CHECK OR FILL IN WHERE APPLICABLE
No....j...Z..
FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application foie Pisponal rr;ods (tunstr on iltrnitt
Application is hereby made for a Permit to Construct
System at:
•
! Location-Addres0
ei{:tJi'.'L.
J /Pruner .
1r.cs r.t
r,€9.an.r
%O %
or Repair (V ) an Individual Sewage Disposal
or Lot No.
Address
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow
Septic Tank—Liquid capacity gallons Length Width
Disposal Trench—No. ............ Width Total Length
Seepage Pit No Diameter Depth below inlet
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
gallons.
Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
Description of Soil
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
ci.....
Nature of Repairs or Alterdtions—Answer wh applicable..
Q a) 4 Xr.? P
a
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 uncle signed further agrees not to place the system in
operation until a Certificate of Compliance has issued by tht rlIck
CtV? -f
Signer
Application Approved By
Application Disapproved for the following reasons
I %Et
Permit No
Issued
;f ,21 /0-at e4
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
AOF POI` P-a4TS
l7Prtifirntt of Tintiptiatta
THIS IS TO CEIRTIFY, »at tl)p Indiy'dual Sewage Disposal System constructed ( ) or Repaired ( ' )
by ( {,(,'. Li..^�I't- L4 Installer
at / =7 /1;eO Xfa-.L
has been installed in accordance with the provisions of Article %I of The State Sanitary r,d e as ,-tescTibed in the
application for Disposal Works Construction Permit No / / ( dated °2 / /16G
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GIMIRANTEE THAT THE
SYSTEM WII,I, FUNCTION SATISFACTORY.
DATE uJP °�°�. i 9‘ ‘ Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CL OF e e-P r e -�.;
NO. __L_71 - d FEE
3isvnsal Marko Eyns .rurtinn thrmit
Permission is hereby grant (_L.4 -.1 0-;-
to Construct ( ) or Repair ( )is n4ividual wage Disposal System
at No i`1-.�`�.:.fir' dA, 1/0 y
:�
as shown on the application for Disposal Works Construction it INp I j , Diked I r / l / G
. ./
.....__...._:_L.r fir: . CMS
T
Board of Health
DATE
FORM 1255 HOBBS B WARREN. INC.. PUBLISHERS
o
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF REALTH
i
Ir(1 7n OF 11r)rThnot+ �ptr>n
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Appr�,anen for:,Pcnnit to Co,nIra„ I i Rt lam r o./1 t puridc I , Abandon t I - V oinl lcic S stcta H Individual(onnponent,
1E3 Truk c St(P al-
(-\ -(cc1Ct-fn CO-
ovilers ,m
i5 Fax____ Prr n -, • G—
5i-'-t . q '533
i srC r/ r,,is, t.tc,,
.,. r ‘'L,e !
C.nvtr Onnunla-1 Fu`.N.1 t nt �
o..ip.
3S513r ,,i�PStrata th ttLp>ct1rr.. .a
5 .� 7aCl
S5- / -) , ,= j
Type of Building: s (- Q i-r . A-i- x_ lot Size Sq.fret
Dwelling—No. of Bedrootwe U =�-- - i 1 Garbage Grinder ( )
Other—.type of Building No. of persons I Showers ( ). Cafeteria ( )
Other fixtures
-
Design Flow(min.required) nod Calculated design flow_ Bpd Dcsg flow provided a� gpd
Plan: Date 5- ,n - r'0 Number of sheets I Revision Date I a
TitleTh G UPI, e �l --,,p(---) -x'1_1 .fit rst:tt T - ( o - Ccf T
YDescription of Sod s) Zll(L L CI-in ��
Soil Evaluator Form No.n Name of Soil Evaluator1M _ /l Date of Evaluation.;} ' i 1
DESCRIPTION OF REPAIRS ORACCERATIONS (1 C.IxJ ■-� ( n 1 CT t ,-ytta.tl L._
Lc;t1--, Atop 3y Xc X15 ' Lcnr'In, nrt 7 ieJ( c.
)
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITU 5 and further agrees not to place e .tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Date 5/3/n
-Signed
Inspect]
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
THE COMMONWEALTH OF MASSACHUSETTS
/1/6fr IdLM1 BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
FEE
Description of Work: XI Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sew on
age Disposal System:Cstructed( I.Repaired.Upgraded( ).Abandoned( )
by: / (/e l n API
at/ I S .2T-1-4.- -7
has been installed in accordance with the provisions of 310{/CM 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. LI - CO dated Q f /i /tom Approved Design Flow -+� (gpd)54 Installer _ L-n^a. 76.e C - -,
f
Designer: 4 CI a � �Inspcctor �� - l ..Date C////l C_Ci
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. 7
THE COMMONWEALTH OF MASSACHUSETTS
/VIP (147/2 $oARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted fp.Eonstruct ( ) Repair (>Q Upgrade
disposal system at /5 n!c-c S�
in the application for Disposal System Construction Permit No. 7 -
Provided: Construction sha l be completed within three years of the date of this perm
Abandon ( ) an individual sewage
as described
;� 5/
Date 4
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 12551 REV 5/961
clIsW HOBBS6 WARREN TM
Board of Health /
PUBLISHERS - BOSTON
dated
v/3%rz
ocgl
erdi?ilsiiuthst be met.