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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 '�'���