43 Applications & Permits THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
G: OF Noralayvp+cn
FEE oV
Appliratinn for Dinpanal 'untrm Tonntrurtinn prrmit
vlication is hereby made for a Permit to Install ( ) or Repair/Replace (✓) an Individual Sewage Disposal System at.
43 W hH4 tr Skee+
_ _ L,.cawn,-ACJ¢as
na"el
DC 111r1 Or mv,u.I
m of Building
Dwelling—No.of Bedrooms 3 Expansion Attic (
Other—Type of Building No.of persons
Other fixtures
:ign Flow 555 gallons per person per day. Calculated daily flow 495 gallons.
'tic Tank—Liquid capacity_INIa gallons Length Ile _Width a" Diameter Depth 64°
posal Trench—No. Width Total Length Total leaching area sq. It.
pnge-RiFAW- 1 Diameter 1$✓<i$t Depth below inlet IQJtt Total leaching arca 04 sq. ft.
ler Distribution box ( ) Dosing tank ( )
colation Tcst Results Performed by 1,Lnvt9ne/PMeFxlwt.. Date 7-31-94
Test Pit No. 1 3 minutes per inch Depth of Test Pit ALJ t Depth to ground water lry
Test Pit No.2 minutes per inch Depth of Test Pit 15: 106 Depth to ground water %
icription of Soil rimy_ 5.;1 valvalw5 -arm
or Let ACI
2 Co. -T. Sasa4* o rinjs NY /2866
Add R,
Address
Size Lot Sq. feet
Garbage Grinder (
( )—Cafeteria ( )
tore of Repairs or Alterations—Answer when applicable Repl a..- S A.5.
to Last Inspected
Agreement:—The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the
provisions of TITLE i of the State Environmental Code The undersigned further agrees not to place the system in operation
until a Certificate el Compliance has been issued by the Board of H
plication Approved By
plication Disapproved for!he following reasons
4S.
onw
Permit No.
Issued
Dnic
THE COMMONWEALTH OF MASSACHUSETTS
KlOr}hamPhcn BOARD OF HEALTH
Crrrtifirate of tlnmplianrr
THIS I: TO CERTIFY, That the
On-Se Sewage Disposal Syste stalled ( ) or Repaired/Re lac
ed itj
I c - by S A1 VQ �+
at d/ 11 AT.I-I I F e" `1 V e cs
been constructed in accordance with the provisions of TITLE 5 of The State Environmental Code as described/in the
lication for Disposal System Construction Permit No. 3 -97 U dated /f — 7 '" / c
of this system is conditioned on compliance with the provisions set forth below:
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEDAS A GUARA/TEEJTHAT THE
;TEM WILL FUNCTION AS DESIGNED. This Certificate expires on J
TE
Inspector
7S r
✓1 � 76, THE COMMONWEALTH OF MASSACHUSETTS
Iv0r4haYMp4tn BOARD OF HEALTH
■ +Diapooal #��eln,(Cnpntrurt}nn lirrmit
,I rmission is hereby granted to Jo,E' / 1 )9 r)f,/if . , *r
ionnstruct ( ) or RepaiyllReplace (<aq On-Site Sewage Disposa4System Iocat d at
ei 93 iJlvtB; "11/4 1 , //< r - 1fl i) / -
siren
n
ekribed on the application for Disposal System Construction Permit.The Applicant recognizes his/her duty to comply
t Title 5 and the following local provisions or special conditions.
c
nstruction st e completed within th
years of the date below.
M1255 (REV.4/95) !FIRS HOBBS 6 WMSENw POBLISHERS BOSTON
THIS FORM APPROVED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION
THE COMMONWEALTH OF MASSACHUSETTS
BOARD �� //
OF HEA TH
OF /yo-1I
Trrtifirtttr of Tumpiitt rr
THIS 'silo pRT Y, T the Individual Sewage Disposal System constructed (X) or Repaired
by
•
at /sat
sa A4y0 1 &tile: ( _. 3XW )
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as scribed in
application for Disposal Works Construction Permit \o..._....LW — 9q dated.. g/..g..st
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTjtUED ASnA GUARANTEE THAT 1
SYSTEM WILL (F,1//NOTION SATISFACTORY. /�—'l-e�:' \ // ,
DATE lj(.L�&A_...../.2 /95C Inspector �`!""�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE TH
OF / M"
�
(Qrrtifirttte of finmplitt r
THIS S C fFyy hat the Individual `Sw:age Disposal System constructed (k) or Repaire
at � ll.r ew rfi S S 0....
has been installed in accordance with the provisions of TITLE, 5 of The State Sanitary Code dessri
application for Disposal Works Construction Permit No / `—g5 dated 9/'.7+""""" '"'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE
SYSTEM WI FUNCTIrON4SAT1SeF�A7$RY. Oro d
DATE 1^=.A Y 1....L.Js._.__ i.,<......__ _....,__—'