985 Applications & Permits CHECK OR FILL IN WHERE APPLICABLE
No...:/...F...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1ppliratiun fur Eiepunat
u,
Application is hereby made for a Permit to Construct
System at: 711r
e '.cP
N. f.oration.ALtlpcssY yr
r
nrk2S ttn82rnrfiun lbrtnit
or Repair ("ran Individual Sewage Disposal
or Lot No.
............._._ -- Address
) F p,mer l'.' f . .-
Installer Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when a,Ppfipble.0
.t u fl.._Lkla� 2J
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 issued by the board of health.
Signed. J ,fg - Date
Application Approved By wry. -s-L �_? °✓krf•'1 ...LZ&.x.j �97a
Date
Application Disapproved for the following reasons'
gyp+-+1 nEfSje" f..4, 14..
Permit No f "
Date
Issued.... lk:L.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�(radiate' of 041mp11antt
M• THI J TO CERRJIFY, T t,the Individual Sewage Disposal System constructed ( ) or Repaired (% )
by 1 ay!rte SY- v-' �,�lk-�-,a,-f'N.. Installer
at /inst:lled.in:.acc accordance �t the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE /G•"�. ; i i.76' Inspector..;=.,("-�-
No // ,i
..1 I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a
Nispnsal, cr;arks (dnnstrnctinn ljermit
Permission is hereby granted .
to Construct ( ) or R ('epair ) an Individual Sawa a Disposal Sys
at No ,,...;y. ..%r� i
as shown on the application for Disposal Works Construction Permit No.` L. _ Dated /__x.. r ✓.71....
FEE fl
DATE
FORM 1253 HOBBS & WARREN. INC.. PUBLISHERS
Board of Hegltb
•
THE COMMONWEALTH'OF MASSACHUSETTS FFE - Li)
BOARD O F HEALTH
pi.40r (4” -"l
OF I. I)IrA \
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construe repair t Upgrade (X) Abandon ( ) - ❑Complete 5.stem _I Individual Components
r
t y
(Li
II 1r
f i e f e t o a r. t\, e a„IFJ)riv
Addres
c„�� —i�l�`
Tulvpenncn
lit t., L k wtu, '1/ , rvlt.L
Duce rnrArrs Nam,
lr-f
nlaprrx«clr
LCIY
nll ,ame
Ina cr,
Address
Add . ,1) - IJ,
- C W
t �� le11/11
Li
TekPhu,c t
Type of Building: I `,Illf_PJL
Dwelling—No.of Bedrooms
d/
Other/41 yee of euildJ Nq!o[persons
O fixtures
Design Flow(min.required) ) 78 epd Calculated design flow
Plan: Date iI II Cl/ Number of sheets
Title I , JEir/, I 1, r ,. r, ,i .V
Description of Soil(s) Pp
Soil Evaluator Form No Ll, ( A Name of Soil Evaluator .4; 111r Date of Evaluation 7j (I",
DESCRIPTION OF REPAIRS OR ALTERATIONS
Lot Size Sq.feet
Garbage G nder ( ) gg
Shower ( 1). Cafete
✓) gpd Design flow provided (/IiCJ gpd
Revision Date -�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Date :-/- ;' %
Inspections
FORM I - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
THE COM ONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CERTIFI ATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) omplete System ,/ "'
The unddjsigned hereby certify that theLSewage Disposal System:Constructed( ).Repaired((Lp :pgradcd h.Hhandoned( )
by: I tab .. y.;(.4,-1-AA-1- 41) h. ?.y26-u, %J i iii- ,n„ AA 1 2 7 _�.
at 7 75 l r."t.` 1CQ (1/;70-. - cirk('4-vl I . , i ',725I`4-&----
has been Installed in accordance with the provisions of 31( CM 15.00 (Title 5) and the approved design plans/as-built
ne
plans relatioapplicationNo. � t �. " dated fI 1)/p . Approved Design Flow (€pd)
Designe /)ti./ /ii /} / /5: Inspector /. liael-�n'e Date 6"/ ,/-5
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
Fir _ (
/
"rid 9
N lj/ THE COMMONWEALTH OF MASSACHUSETTS FEE
7/s` p7%/Y/iib( BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby ranted ty.Construct ( ) Repair (Vl Jpgrade ( ) Abandon/( ) an individual sewage
disposal system at ( ` , -/ 2-;' L2"- — (I'-0-t2v - </.7, .. ^ a. R. described
in the application for Disposal System Construction Permit No. fl f/ - /�-/ dated <J) /C .
Provided: Construction shall be completed within three years of the date of this permit. All local conditions/must he met.
Date 7 / /: OW Board of Health t,--T-Cr; '{
/ ,,L.
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 L REV 5/961
HEW) HoeBs n WARREN TM
PUBLISHERS- BOSTON
CHECK OR FILL IN WHERE APPLICABLE
)
No
Err
THE COMMONWEALTH OF MASSACHUSETTS
Fun `# 0 0
BOARD O. F HEALTH
1.. . OF /.,t<'.e7rn�U�.:r�
Application for Eltoponal Ili arks &noirur#ion Iltrmit
Application is hereby made for a Permit to Construct ( ) or Repair (/' ) an Individual Sewage Disposal
System at: n ,}{
Locati.r9ddress
4k.4`
or Lot No.
.Owns Address
(.24`I`st ✓ �
Installer Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable-id. .�
• .. 9▪ �04g t
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 issued by the board of health.
Stoned •..J.a Lt i �:::-.:f,'a.
a<
Application Approved By �„{s tt "µxs s�:t Z6Ya/.r%.1.1i.....
Application Disapproved for the following reasons•
0-4 igimtd
> Date
Permit No .r'... Issued.'. .-241 770
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF l*SCr-rnicAll
trtifiratt at eontoltatut
THIS 0 CER,TIF:31, That the Individual Sewage Disposal System constructed ( ) or Repaired
14-"Lide.t. dr.
Installer
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No
dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Pei ;at 171e
No V () 1
( ■111
Inspector...iaire4I-SE.L.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Lill
OF 4,,cf Dre -n i
Biopooal,
nrkM Conotruction frrinit
is
Permission is hereby granted. ... ......tit
to Construct ( ) or ?pair ( ) an Individual Sewage Disposal System
FEgST 0141—
at No of,.464baise "t,a4
street r
as shown on the application for Disposal Works Construction Permit No. `zild
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Boa of H