132 Applications & Permits No...:1 =' 7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�A LL
OF ih"""'o-
Applirtttinn fur Ilispnsttl in nrks (Lnnstrnrtinn rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (Kan Individual Sewage Disposal
System at: )
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench No
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No of persons Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter Depth
Width Total Length Total leaching area sq. ft.
Diameter Depth below inlet Total leaching area sq. ft.
) 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. . fr„_ iezc....Ce r%x <"'Ad A,yet1, /-5 -Clezh
U rl-L4'
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 beep issued by he board of health. � �/
Signed..
r 6c.... ... .
Application Approved By J.-t a-t .: " ) ILO; bate
Application Disapproved for the following reasons•
Permit No 171.0 7
Date
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' OF /),
&ridicule of TnittpThiatur
THIS 1$ TO CE (TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (e ).'
I? "
by Installer
(f at / •12
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 %LC / dated /La :Av../ 1 t"
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ' 1 1 74" Inspector T 1;1
'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a-
OF bz,,ge-c
No 7 / (.2
niglinattl arks Tonstruttinn Permit
Permission is hereby granted,
to Construct ( ,) or Repair c1 -an Indwuli#1 Sewage Disposal System
at No
Street /
as shown on the application for Disposal Works Construction Permit No l-1 Dated .
Board of Hata
J 4
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
\pplication for
COMMONWL,ALTE y(W NASS\L IIUSL.TTS
it`-
Board of Health. N -t .HICMPT V3 MA.
APPLICATION FOR DISPOSAL SYSTP1 CONSTRUCTION PERM!
FEEl — V
Type of Building EVVSi' 1)/ 'e-UuJC. Lot Size sq.ft.
Dwellin g . o.of Bedrooms Garbage grinder NO
N_
Other-Type of Building No.of persons Showers( ),Cafeteria ( )
Other Fixtures
Design Flow (min.required) 33b gpd Calculated design flow 3 SS Z Design flow prmided 3SS,L gpd
Plan: Date S c t DI Number of hertz Revision Date
Title 5 if el-v Sptu i 2672m& D PC.RA-DE le)(- (2, 2_Lo-ZT i-AN M S .Crr c
Description of Soil(s) GLRSS-1- SatL — S _r2
Soil Evaluator Form No. (plei Name of Soil Evaluator 1 .nail eld Date of Evaluation y/.RQVD/
DESCRIPTION OF REPAIRS OR ALTERAI IONS —A1S7-/i'L C- ,tX74J <--- /'U6 4??cU) L=- :sip x
W = I i pee n+ =9' As POL /"7tm- A--,c) rnaer
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees of to llasee the em in operatic' til a Certifica of Compliance has been issued by the Board of Health.
Signed NLY'/ Dat r�VG'
Inspections
' Location 132 Lass; FARMS tetvRD
Owner's Name GN-J O C4 s./
1
Map/Farrel#
•+t
t ,
Address 4 3 n; I UC � .''-�
Q.Fifl R�
14
/n9'
Lot#
felepbone# 413 -5-. 5%Q6 Cat ,56„,4.6931
Installer's Name C.412 IS SEe.c2sz Sc ni
Designer's Name ERA 651- J )41A1-4-44 VS
Address (31,,,2 A-Lb r- 1 hi Sr w4)w1,) rrFA-
Address lie: Q kii€y (ZofO , Cx+tw , m,0—
II Telephone# 41 �— 5?1 3-3L3?,
Telephone# 41 -513 SD33
Type of Building EVVSi' 1)/ 'e-UuJC. Lot Size sq.ft.
Dwellin g . o.of Bedrooms Garbage grinder NO
N_
Other-Type of Building No.of persons Showers( ),Cafeteria ( )
Other Fixtures
Design Flow (min.required) 33b gpd Calculated design flow 3 SS Z Design flow prmided 3SS,L gpd
Plan: Date S c t DI Number of hertz Revision Date
Title 5 if el-v Sptu i 2672m& D PC.RA-DE le)(- (2, 2_Lo-ZT i-AN M S .Crr c
Description of Soil(s) GLRSS-1- SatL — S _r2
Soil Evaluator Form No. (plei Name of Soil Evaluator 1 .nail eld Date of Evaluation y/.RQVD/
DESCRIPTION OF REPAIRS OR ALTERAI IONS —A1S7-/i'L C- ,tX74J <--- /'U6 4??cU) L=- :sip x
W = I i pee n+ =9' As POL /"7tm- A--,c) rnaer
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees of to llasee the em in operatic' til a Certifica of Compliance has been issued by the Board of Health.
Signed NLY'/ Dat r�VG'
Inspections
C /-
CI)'1 1OlNl\\'F,1LJF1 OF 1\1A'SSAIITRISFTTS
Boreal of Health.
IJ:PT11=1C;IL OF Lo1'1PLLAN'CF
Description of Work: J Individual Component(s) J Complete System
The ondeut lied herchv cerrif Odd the Sewage Di.pnsal System: Consmmred
br: 1/S.
at /3z —
Repaired
FIE
Upgraded ( ).Abandoned ( )
has been installed accord h uc with the p (> >Ci 10 CAIR I DO (fide 5) >>d she apps 1 de pla milt plan: elating
apps idiom No. O/-2. sated S" /y/0/- Apt :c ed Design Flow 3 gpd)
Instiller
Dc.ig r:_ -d 7
h
Dare: Co//14 /
The issuance of this permit shall not be construed as a guarantee that the system will function as designed
Silo/ G ;
CO MONWhidill O1= ) 1:1SSt CI1l!SLTIS
BOOM„iHeank,
DISPOSAL S'STIN CONSTPI'CII)N 1?Fl?�11I
4
FEE 3'
Permission is het thy granted to; Construct( ) Repair(/ Upgrade( ) Abandon( )an individual sewage disposal system
�h1L as described in the application for
at �3,D kosf al14& i
Dispc cal 5vsrem Couslnicdon Permit No. i�V-5 dated 37/(///.
Provided: (:on s i l t c don shall be completed within three veins of the date of this in .y loyal co ns must be met
Date-6/1V Board of Health ° -4/ // e'Ff---•--,'C- .