237 Applications & Permits COMMONWEALTH OF MASSACHUSETTS
Board of Health,
CERTIFICATE OF COMPLIANCE
ascription at Work U individual Component(q )(Complete Spbm
ae uMenigned hereby Gentry hit the Sewage Disposal System;Consmrcted( ). Repaired( ). Upgraded(),Abando
1af/&cC AWL,
?37 . wes-fhat,p-
s been installed in ccordance with the pro iAi s or 310 CMR 15.00(Title 5) I the approved design piansns.buill plans relating m
plintion No. M 7dn<d Approved Design flow
(and)
faller
"{goer Ana <'/jNtei
Inspector
L6.—J Dale 7/J -./y
e issuance or this permit shall not he remitted as a pat runlet that the Dorm will function as (It-argued
CEr 41-apgwn Fops 5196
FORM 2 - DSC `�
red ap
r/»/f,
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Neffeta- 0e7 . MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
nissinn is hereby g((a Bled In: Construct( ) RepaitX) UpgradeI I Aha ndonl I an individual sewage disposal system
��7 WCSt{Ik�t,%ip'p '\
em Consuuclion Permit Nn. , dated 515197
'Med:Construction shall be completed w'thin three years or the date or this remit. All
#r Armin°MR/ 5/96 Date-P/97 RruNnlllealth � •
as described in the application rot Disposal
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NaitH/ FORM I - APPLICATION FOR DSCP
Fee—cAfl�
COMMONWEALTH OF MASSACIIUSEITS
Board of health, Wcr Sam/In? , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a/emit to Comtism!()Rereir 1),.alrpnJe()Abandon( )-}a'Comprle Fyerem ❑Individual Cemponenis
Location S41'I)e ------ .---e
Owner's Name fVA(irce/ IIC121
ht.Nr.¢<IR Address 0237 Ussftiam In/
Lov P / d, /Uor/y D,FJ
/� Telephone/ (1/3)5821-9/5? �aGD
Instsller's Name Dena arns/r✓c /. R1U"I rye a /? /, (5'4a
sh Unigner's Mime /im/1C>5 f EE.'
- Address v�! rt�rhe<�i nVj«
Address PU, SOK L??/d, %,7764,31, MA
' Telephone/ --- Telephone/ Otooq-z;ice
(9/31-265-.3'7(.00
Type or Building: SYf/ -----
Dwelling-No. of Bedrooms Jr -- Lm Site_ eq.0_
Other-Tyre at DuilJing 4°bsge grinder( )no
Other Fimm�s No. or persons ), Ofuaia( )
Design Flo.ml ed) 330 RN Caculaied design now 120 .
Plan:Dale 16/7/17 Number of sheets gal RN Design flow rmvided y-�gpd
Title "Qn -s1k S Revisi�npur�re pi.
•
Description of Saille) in c.- 1 1
Soil Ernlustm Form No. Mime of Soil Evtlnanr •per ,ver Due of Evaluation 2//l8/77
D CRIPTION OF REPAIRS OR ALTERATIONS L- AL
[i .E. 0.O ���� - / <
' 4! (s+ SO' / X Jr ,-/ `w •wu�-�Tl v
T he undersigned agree.to Install she above described Individual Sewage Dispos.l System In accordant.with the pro'Nlam or TITLE
3 and further agrees not to/plate Ihr sperm
/''In operation wild a Certificate or Compliance has been blued by the Rimed of Health.
Signed /�CYHA,/ ,�7-C`)^'tt. (TLS✓- Oedkce- ffc' Uare P/RI / /
Impcdnm
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G. DEP APPROVE11 FORM 57(96
1010 13 - CERTIFICATE-OF COAirUNRCE
No.
• ittt �.e •
ww
FORM I - APPLICATION FOR DSCI'
'kJ ,34
Tee
COMMONWEALTH OF MASSACHUSETTS
Board of llenith, /Ver—Ma.,.rp{ioy , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for•Permii in Connmu O Repair r1s'(Ipgnde()Abandon( ) •, tomplefe System CInA,ldue!Components
ril.
Location �Ugyte %1T - Owner's Name
Waif fern., Her ZI .
nl.prnrsel/ Address 0237 klesf1 n,p,ls, Ad, Nor/4ory'Ary,/08
tOLori Telephoner (MI3)5f3y-9157 0/060
Installers Name D Jib fyr ./i D R rll,.��- PE. �ebf,S4vc,-
v< m-r esigner%Name G t
Address Address P0, Bo,, (93/&, Am4US-4 mA •
D-Telephone/ Telephone/ ("5//3�e765—SY00 o/onY- x/�
Type of Building: 5(H -_.. --T- Lot Sin sT.lt Dwelling•No.of Bedrooms Carhop grinder( )g70
O
•
ther-Type of Building No. of persons Showers( ). Cafeteria( )Other Fixtures
Deign Flow mi d) 330 gpd Calculated design flow 9ZOgNI Design flow provided- O gpd
Ran: Dalebi 77 Numbs of sheers Revi,inn ODaule
Title ().'I -S,Je S+M,a bra, la c-Cy s/ni ter
u �'
Deariplion of Soil(s) Akan G
: mm i/� O
Soil Evaluator Form No. Name of Soil Enh obet t Ida vv Doe of Evaluation //�/p/77
D• CRIPTION OF REPAIRS OR ALTERATIONS /• //a 14./1 a. a! - a
rs ,L. 0.0
• et c LI,d to' / x /4'W �
The undenlgned agrees la Install the @love dncrlbed Individual Sewage Disposal System In accordance with the previsions or TITLE
5 rand further agrees nal to plate the at,lens In oper.11on until•Cerllfiale of Compliance has been hoed by the Hoard of Ilealih,
Signed .0 c/x,„/ ,d J-c)-w. (4 Wa//erg Nec Dale F3/R I 97
.
Imperllom
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G. DEP APPROVED FORM P95
' FORM 3 - CERTIFICATE-OF COMPLIANCE
No.
No.
FORM 1 - APPLICATION FOR DSCP
Fee
COMMONWEALTII OF MASSACHUSETTS
Board of Health, j✓OV-fhat fF+y , AfA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Applieuion for a Pentair to Conntuct()Repair IIl'[Ipgatle() Abandon()-,vCemplete System Lllndl.ldual Componeni,
Location
di/hL
Owners Name r\Idirges_ HCrV
Address ,.-2.37 UCsfl&Mf]ni Ad 144/4y'4,
00/o/(oD
Telephone/ (4/3)55341—9/5?
Designer's Name Q/m 'T.[°r{ai 1 7 1 E&7 t S
/pf mh
(n 1' l P n3nECNyr
Map/parcel/
Lot/
Insulter'.Name
Drib
J frvc4oin
Adders
p Dm�af
Address /�U, Soy W/a, /TP/14fjS1/ MA O
Telephone/
Telephone/ w/1)„260-3 bec OrooY33/z
Type of Building' .S FH
Dwelling-No.of Bedmnm, a
Other•Type of Building
Other natures
Lot Sire sq.ft.
Garbage ponder( )/70
No. of persons Showers( L Catae tia( )
Design Flowr{m,i ¢ ed) 33o grad Calculated design flow YZo gld Design flow provided 9-4p ppd
Plan:Date be f 7/ 7 Number of sheets Revision Date
Title "Om -S.k S�.1-'a/wait h,siod a/ J strm eea�a/i'
Description of Soins) Ay{fyta , q P
Soil Evaluator Form No Name of Sail Evaluator /2 be��' 1J b,vrr/,JDate of Evaluation 41/48797
D'SCRITION OF REPAIRS OR ALTERATIONS /% /,�, /�//yL �� q(, Qe /�
O/G : Jr i �./
a 4 g.-.f min/ / X /4 in/ ,
the undenigned eertes to Innl•l the .lave described Individual Sewage Disposal Syalem In accordance with the prarklnm of TITLE
f and/ureb%eet/agree/not in/plate the myatemIn operation until•Certificate of Compliance hat been kneed by the Board of Health.
Signed /(q�P�j Y"D>wL �7ZI tJa//o[e /Per l Diu. I Y /
tragedians
D. DEP APPROVED FORM 5196
FORM 3 - CERTILICA'I'E OF COMPLIANCE
No.
COMMONVVEALTII OF MASSACHUSETTS
Board of HealU(,_ (Ud/Y'Liu
•
CERTIFICATE OF COMPLIANCE
D eacripllon or IVora: U Individual Componential 'Uomplate Se slam
The undersigned hereby certify that the Sewage Disposal System: Concinrcled O Repaired( 1. upgraded( l(Li
k2 by: alusts iler21 N(Lk2 ."/l. gib!
.t ?37 . wcs tha4,i k, Geced.
has been installed in accordance with the provisions of 310 CAW IS 00(Title 5)and the approved design piom:II-built plans relating to
application No dated _ Approe rd Derign Mow__ _(gm.1)
Installer
D esigned Inspertor Dale
The issuance of this permit shall not he construed as a guarantee that the el at em n111 ftmclioo as thalami(.
° r[r apnrpn a= TOW 5/96
No.
. FORM 2 - DSCP
pee
COMMONWEALTH OF MASSACHUSETTS
Board of Health, � {-G,anr�¢, >7 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herelIu !canted to; Connor A I Repaitr Vl Upgrade( 1 Abandon( ) an individual sewage disposal system
,
at g37 WlftAGM1ha9 as dexribed in die application for Disposal
System Construction Permit No. dated
Prodded:Construction shall be completed wiihin three years of the date of This pe mtil. All local coal ii inns maw he met.
(d
MVP Arran ID,oRt 5/96 Date Ruatdof Health
THE COMMONWEALTH OF MASSACHUSETTS
BOARD�% —OF OF�HEALTH
.4pplirafiun fur 1inpnnal
Application is hereby made for a Permit to Construct
ystem at:
- 3 7
ion•Addr
)4-cg
grv�er/� Address
i f�.�i Lai(:
r
F„,_5; e C
nrkn Tut-intuition Permit
or Repair (v) an Individual Sewage Disposal
or Lot No.
Irmaller
ype of Building
Dwelling—No. of Bedrooms Expansion At
Other—Type of Building No. of persons
Other fixtures
resign Flow gallons per person per day. Total daily flow gallons.
.optic Tank—Liquid capacity gallons Length Width Diameter Depth
lisposal Trench—No. Width Total Length Total leaching area sq. ft.
eepage Pit No 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
Address
Size Lot Sq. feet
c ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
)ther Distribution box
'ercolation Test Results
Test Pit No. 1
Test Pit No. 2
)escription of Soil
Sature of Repairs or Alterations—Answer when applicable.'d4
etce-ce.tel.«.
lgreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
he 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 yJ
\pplication Approved By X .f:t )L
application Disapproved for the following reasons•
».
3P 97/
taste
Permit No..-I 7 Li
Date
Issued .3,..L_ ZJ
ly
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifiratr of ftnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
as been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
pplication for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
IYSTEM WILL FUNCTION SATISFACTORY.
)ATE Inspector
.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(AV OF f..1.G.14=1.:IkYI[?4-`Sj
ElispnsaJ 1 C arks fdnnntroriinn Prrmit
Permission is hereby granted./.... ' 'r?4t ? L .4LL-A
) Construct ( ) or Reppir (Y,) an Individualt,Sewage Disposal System
No :sZ.3...7_.._ :YSsY�i�ttiyr. _.v1�<
street
shown on the application for Disposal Works Construction PPermit No:2 7Y Dated_ ....._Ll/
idisCit
FEE OO
PATE
)RM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Darn of 7katm