140 Septic Applications Permits & Compliance CHECK OR FILL IN WHERE APPLICABLE
No FEE..........
_..._.....,.
THE COMMONWEALTH OP MASSACHUSETTS
BOARD OF HEALTH
Application for fliupusnl rr;urk,u (duttutrurtiun hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
0,-i•
^^-1......A Owner
mean
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow ) gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacityl0./%IZ.gallons length Width Diameter Depth
Disposal Trench—No Width..a.. __.._ Total Length.. Q.__... Total leaching area.... a Q sq.ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
ft-
Addrne
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
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
Description 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 XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issled by the board of health.
L ..
Signed it -r W�.._ -a r
Application Approved By �`%e` x— �' `��.IF".n et n i tt-da >• j /IE t
n(
Date
Application Disapproved for the following reasons•
Permit No
Issued
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
�/ OF HEALTH
OF I iGY7h(-a-tw
(J tdertifitate of thnn4lianre �
THIS IS TO 4'ERTIFY, That yr Individual-Sewage Disposal System constructed J or Repaired ( )
i r
Installer
at / ./ ✓ u--. , — .
has been installed in accordance with the provisions of Article X kof The State Sanitary ode as described_in the
application for Disposal Works Construction Permit No )S' dated_yyi- cl Ifi°2
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. , -
DATP tiy"�-t i I c '� Inspector. ; ,}'� �t. l a'Qiw /a7
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF Terri a.-t-7-7
Uispnsaaj H nib Catntrftetinn rermit
Permission hereby granted..e � ' it [•n�(.y.
to Construe or $enair (1 Individual Sewage Di sal System
at No r Y iiI!/1"--f
FEE
Street p
as shown on the application for Disposal Works Construction Permit,No Dated
DATE Ike' n't"-. ) 'i
1255 ItOass & WARREN. INC., PUBLISHERS
/ I-
Roar/of Health
Applicat fora
COMMONWN9 ALAI I MASSACHIISLTTS
9y
EG yg33
APPLICATION FOR DIS1 AL,E SY TDI CONSTRL'CTLON PERMIT
Permit t Construct( Repair tpgmdc( AbandonO - o plem System
❑Individual Compone
L
(40 hi Ir S%
Ow Name A i'.*Th *(4e..� I Ac&
Map/Parcel#
Address / r�% �%
Lot#
Telephone# .Sec--9% y
li'staller'.s Name
N ST
Designer's Name ' L AL
a
Address
/
Address in tetstrinti 44-)
Telephone#
A
- 7- Z
Telephone#
Si? -
Type of Building
Dwelling-No. of Bedrooms
Other-Type of Building
Other Fixtn1es
Ft9
3
I-ot Site Z9Y 000 ;/ sq.ft.
Garbage grinder
( S
No.of rersons Showers( )-Cafeteria )
Design Flow(min re uired) (/O gpd Calculated design flow Y9C Design flow provided
Tide 'err ((P-
•
Plan: Date i Number of sheets
Set c 151t 'e
Description of Soil(s)
Soil Evaluator Form No.
Recision Date
3vr gpd
DE IRIPTION OF REPAIRS OR ALTERATIONS
(I
Name of Soil Evaluator A(deo;5V Date of Evaluation
The undersign. a ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
*tither afire
to rot to plan th
operation until a Certificate of Compliance has been issued by the Board of Health.
�/ t �/
tgnea ter- i� w� - -G� Date dZ
Inspections
No-n
COMMON\Z/LALTII OF MASSACHUSETTS
Board of Health,
MA.
CERTIFICATE Of COMPLIANCE
Description of Work: O Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed
bv:
at
has been installed in accordance with the provisions of 910 CMR 15.00 (Title 5) and the approved design plans/as-built plans relauug to
application No. dated . Approved Design Flow (gpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FEE
Repaired ( )_Upgraded ( ),Abandoned ( )
COMMONIWLALTTI OF MASS.AC-IUSFI'IS
FEE
Board of Health, MA.
C£RTIFICATF OF COMPIIANIT1
Description of Work: ]Individual Component(s) ❑Complete System
the undersigned hereby certify that the Sewage Disposal System; Constructed ( Repaired ( ). Upgraded ( ),Abandoned ( )
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the pp red design plans/as-holit plan,relating U
application No. . dated Approved Design Flow (gpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEA[111 OF MASSACI}USETTS
Board ofllmlth,
DISPOSAL SYSTEM CONIS4RITCTI0N1 PKRMIT
Permission is hereby gra d to; Construct(EA-1-
) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at / T /: b`( J/
Disposal System Construction Permit No. /9 t.')` dated
7/7/ )-
as described in the application for
Provided Construction shall be completed within three years of the date of this,p I piit.TII local con iohs must be met.
2; � , i
Form las Rev sw AM Shcen co.Boston MA Date i% dLf-Board of Health _ ,. /i '�'���