178 Applications & Permits No
THE COMMONWEALTH OF MASSACHUSETTS
n n,
BOARD/ OFF HEALTH
�/ % OF ,UJ l( 9 /r 74/
F SG.at
/tie) ,ae.,Cee
33.40
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIOS),PF NIIyT���
) - u Complete System nddntdua /omponenC 4"ec
iwnon for a Permit o Construct f I Repair (
Upgrade ( ) Abandon I
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ldcPannex
Type of Building: - frL-j7jviNt Lot Size Sq.feet
Dwelling *No.of Bedrooms t zt Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ). Cafeteria ( )
Other fixtures
Design Flow(min.
Plan: D
Title
fired)
4 •
r '
d Calculated
Dam
fug
of Soils) �rO UQ I 547j.b
Name of Soil
Description
Soil Evaluator Form No.
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
• ' 1 •• __ e/a
• •
design fl
i L o
Revision D
i' C :rI r —
valuate Date of Evaluation
afn
Design fl
gpd
A- aesiiigair
u / •
L•
2
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.
Signed
Inspection
Date
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. 494,11f :4 THE COMMONWEALTH OF MASSACHUSETTS
J /Un 440ALBOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
mplete System /_Jt
by certify that the Sewage Disposal System:Constructed( ).Repaired( .Upgraded( ).Abandoned( )
G9Q�cil�
Description of Work:
The undersigned
by : lC
/7
Individual Component(s)
FEE i” 12/
od �nr., /may,''';: %n✓l
/r t t 7 { iZ t' S- Dr--c.
at
h b installed 'n accordance with the provisions of 31f1 C it t5.00 ( le 5) and the approved design plpn)s( built
:-� / T �IV//
Installer c- . / - . MA — y !
z� /) t z
dl ��nspcctor / Jij Date u r. .�t 1 %/
Designer: iI) [[[„,,nb
The issuance of this dertificate shall not be construed as a guKranrea that the system will function as desigded.
has been
1
plans relating to application No.i�i90 ll-,�� dated LQ 7 7) . Approved Design Flow (gpd)
FORM 3 - CERTIFICATE OF COMPLIANCE
DEP APPROVED FORM 5/96
No g -ny( s lEj THE COMMONWEALTH OF MASSACHUSETTS
,OO8y7Jlf/I /HOARD OF HEALTH
FEE r"
4/
DISPOSAL SYSTEM CONSTJICJCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) an individual sewage
disposal system at /77(e b,i G F t A.� (_ [,�- r�co Z'1'�s derscribed
U � dated a / �)7
in the application for Disposal System Construction Permit No.
Provided: Construct on shall�be completed within three years of the date of this pen '
All Iocal,conditions
Board of Health I/I �. '�. c -
Date
0 "7 nf�
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 IREV 5/961
�IItWI) HOBes&WARREN.'
NEE
PUBLISHERS - BOSTON
he met.
No «3
THE COMMONWEALTH OF MASSACHUSETTS
e�OARDOF� QHEALTH
OF ....� .u. .rt.'^u'.
Applira1iun -fur Uiu}tuuttl 1flurk0 k!Iuualruth it lirruttt
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Faa `-� ' C
Y [
System at: .T' ��
/�_ _ fir or Lot No.
C-tAk atbrunt.//i
t,:tate` Size Lot Sq. feet
Type of Dwelling Building Expansion Attic ( ) Garbage Grinder ( )
Otr—Type of Bedrooms Po — Cafeteria ( )—
Other—Type of building
No. of persons Showers ( )
Other fixtures gallon.
Design Flow gallons per person per day. Total daily flow — Depth
gallons Length Wild: Diameter p
Septic l uk—f—N capacity gir 'fond leaching area
Width 'Dotal Length
Disposal Pit No—No. Depth below inlet Total leaching are- sq. ti.
Seepage Pit No Diameter i
Other Distribution box ( ) Dosing tank ( )
Date
Percolation Test Results Performed by - Depth to ground water_
Test Pit No. 1 minutes per inch Depth of Test Pit 7 g
Test Pit No. minutes per inch Depth of "1 ea Pit
Depth to ground water
Address
Address
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
toaeP
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article AI 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- y
� f
,l 47
Application Approved By �i�"-°'/�°4�"-- I/ J • I_. Date
Application Disapproved for the foFlovsn,V reasons:
/ Issued 4- 1 ] 7
Permit No.-.1/" Date
by
of (Itnm�thuntP or Repaired THIS S TO CERILFYg,TIwt the Individual Sewage Disposal System constructed ( ) p (4/
at 1.1 C /i 3 `=
has been installed in accordance with the provisions of Article XI State Sanitary
application for Disposal Works Construction Permit No !C dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A
SYSTEM WILL FUNCTION SATISFACTORY.
DATF
(Britt-titan)
1 nstaller
$ 192.7
No.
Inspector
Qr.
. tla:_ir�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Code as described in the
,12-e-1.41
UARANTEE THAT THE
-r
Bispnsttl ifinrks QInitatruttinn 1JPrmit
FEE
Permission is hereby aiante4e
to Construct ( ) or Repair (✓) an Individual Sewage Disposal System
at No t . Street
as shown on the application for Disposal \Vorks Construction Permit No
DATE
FORM 1255 HOBOS & WARREN. I PUBLISHERS
Dated
Eon rd of Meant/ - f
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Fss....._............._._.....
Applitntion for Disposal rr;arks «ionstrurtion 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal
System at:
Location-Address
Ow7je, i....
installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building No. of persons
Other fixtures
Design Flow gallons p
Septic Tank—Liquid capacity gallons
Disposal Trench—No Width
Seepage Pit No Diameter
Other Distribution box ( ) Dosing
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch Depth of Test Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
or Lot No.
Address
Expansion Attic (
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
er person per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area . sq. ft.
tank ( )
Description of Soil
Date
Depth to ground water
Depth to ground water
Nature of Repairs or Alterations—Answer when applicable :e.„4.44;w1s r'
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
Application Approved By
Date
Application Disapproved for the following reasons'
Permit No
Issued
Dam
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF. '
Qtrr ..'� .fr...,.....I1`.il
tifuutr_nf fQnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
by
Installer
at 1--i...f......._It....:t 2:2.ess.r...
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 Inspector J-! ;Lbw . -
No .M1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
F
Disposal
new kinnstrurtiun jrrmit
Permission is hereby granted `
to Construct ( ) or Repair ( •")^an Individual Sewagg.Disposal System
at No L
Street
as shown on the application for Disposal Works Construction Permit No
DATE ',jaw" '
�l
FORM 1255 HOBBS & WARREN. INC., PURL/SHOOS
Dated
FEE
Board of.'Health