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VILLAGE INSTALLER'S NAME i ADDRESS sl' do. te,41? . BUILDER OR OWNER FDA T E PERMIT ISSUED :219- DATE COMPLIANCE ISSUED b=Q iU�� r�n�c �•�c T •�, ch of � !° loop i `�I . 4Ary y� 7 � e THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (�2�! ................ ................................. Appliration for Disposal Works Tonstrudiun 1hrmi# Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: _ :. ............... .. ................ ® -�,.. ..-....... .�. a L l ...... ..... Location-Add or , P ...............................: r� .f _. .�_. a.. �,! n �A�J� Address Installer Address Type of Building Size LotZ-5�?C.Z')..._..Sq. feet �.. Dwelling—No. of Bedrooms..........-.�,.?�5........................... Attic ( ) Garbage Grinder ( ) Other—T e of Building ........ No. of persons............................ Showers — Cafeteria a' Other fixtures ............................................... W Design Flow........-5-S........................gallons per person per day. Total daily flow.......33C�?.....................gallons. WSeptic Tank—Liquid ca acit/ allons Leng the '.¢.._ Width_!%"4... Diameter................ Depth,S-�t_.. x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area_...................sq. ft. Seepage Pit No....... ............ Diameter./C.)......... Depth below inlet............ Total leaching area,-SS ..sq. ft. Z Other Distribution box ( �� Dosing tank1.4 ( ) 4 Percolation Test Results Performed by...04,E.. ...�� ^..� ................. Date_.a - 4 Test Pit No. 1__`_Z..minutes per inch Depth of Test Pit./ .... Depth to ground water....X— «-------- fZ4 Test Pit No. 2..L:K:n.minutesper inch Depth of Test Pit/ ram.... Depth to ground water.. . . O Description of Soil_ Q..�...- ----•----------------------- �� �:.=. " ---. `" ! -:------------------------ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ......................................................-................................................................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance issue y the o health. Signed ,, •• ......•••......... Zi t ate ' Application Approved By...... ........ ate Application Disapproved for the following reasons:................................................................._...--------------------...----------------- ••......•-•--....•---•....-••••-•••••...........•-•------•--.....•--•--•--•--•--••-••------••-----•-•-•----•••-••-•••-•-......_•----------------------•-•--•---•--------•-----•---•--------•-••••----- Date PermitNo................................................. Issued........................................................ Date No. ./q� F$s.... .5_u ...._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Alipfiration for Disposal Works. Tonotrudion 1rrutit Application is hereby made for a Permit to Construct ( 41-er Repair ( ) an Individual Sewage Disposal System at: ?....................... .................,. ©l //................ .. ��/JLooccajtiion--Address 1 �/}�y.�/) or/A Lot No. /��/ .. �wJ..11�I..Yir. .- .......w_.w-•-•_•-•_w____._.w-- T.. .[ /I..:.. 1./�VC.. �.G....�'••f_iA�A..�.i...! :.1 J ner Address Installer Address Type of.Building Size Lot��-:-z Sq. feet �-, Dwelling—No. of Bedrooms...........3...........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building .. No. of persons............................ Showers � YP g -----------------•-------- P ( ) — Cafeteria ( ) d Other fixtures ........ ...... :_......__... Design Flow....... ....................... lons er erson er da . Total daily flow....... gallons. W gn -.';,�••- - I;� P P P Y Y �d--------------------- WSeptic 'tank—Liquid Li uid ca acit Ions Le P q , P Y/dal gt1 4.F---_L4---- Width./.__-..._ Diameter................ DepthS._�_... x Disposal Trench—No...:%................ Width....................Total~Length...................,.Total leaching area................_...sq. ft. Seepage Pit No...... /-........... Diameter./p.......... Depth below inlet..g::;............ Total leaching area_SS'<2..sq. ft. z Other Distribution box ( 44'0/ Dosing tank ( ) Percolation Test Results Performed by._.,t'�E7���j__._494(lee: ..................... Date._.3. . c/vZ ,-1 f Test Pit No. 1...*d'Z..minutes per inch Depth of Test Pit./ iP.-'-.. Depth to ground water....�'K_._........ f4 Test Pit No. 2.. .- r.minutesper inch Depth of Test Pit,/-�r-�..... Depth to ground water._�jl�j.......... w ................................ ..............'_.. ......_...�.............................._....................__......................._...... O Description of Soil . .. 4l.f oe..%EEZ4j0P0 04.-04= ---C.G � yl._-. 49- !-''-, �tc.�� .Q..--.�..�a t.� �"b ------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------------------------•----------...................................--•---......_...........•-••-•--•------••••..................•--•••••.......................--•••-------•-•-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h s y the b' of health. 00 Signed o- t............................... ......0/ e Application Approved By...... :...... Application Disapproved for the following reasons:........................•.--........--...._............___._....___.__....••_•------------••-•------..... - ..............•-•-•..........................•••-•-•----•........•-•--•-••••-•...-••---•••••-•--•--•••w.•••••••-•-....................-----•---....-•••--.........--............•-•.............••----. Date PermitNo...................................................w.... Issued.................. ...._...._... - --------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH w- TQ(,,c.•%(,�...............OF.. y �Z,i• 3 ............................. (9rrtifirate of Touts hattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( fir-Repaired ( ) by..... �/+�........,1'�• ,/`1 ----------------------•--•---------------------....................... Installer at.. ,►4::4 ice"" 1 A Q Pof2.l -�----------------------.------------..............------------------------------. has been installed in accordance with the provisions of TIT I F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-8 _- .................. dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SAT)SFACTORY. DATE............. �.. 4.9l ............ Inspector----- .. ,1? --.-.---------.-------------•--------------.-------.----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .,0........... w Disposal Works Tunutrttrtion rrutit Permission is hereby granted..4( .....eQ.......��- .. - --------------------------•--------.....................----•-. to Construct (C.-y"'or Repair ( ) an Individual Sewage Disposal System at No... ._ f�',Q . Street as shown on the application for Disposal Works Construction Permit No..................... Dated.....................:.................... r' ✓�� of Health DATE..........•••........................................ ............... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 4 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA X;_?...�r..wr '3+---.+f'w-�+u rw+�1�..-r..,. .b.�..r_. - - - - -,r...,..c..-r..r+�.•W.w.S. rl.-�-' , - acrrw•.�-�.Y,...w�«,+ - .,.-..�..rw.,........ y/. . .. ... a' +j -. k .;:. .r:�-�� t r: yti + r i 4. "'a„".., ,... .c.ssa r .•'. µar ,„t^rw�+!1 _ s-'t' y.I-I,F -.r'd,'r"�'• "d / _•,I - fir,. + �_1; �� _ aG.t e. P �.y- : .. '}•,�•.a'•.. �-,,.,r+�' r •'-r'�, ..k-e_r,'6 . II ir CI- +t,,,('I -f lx ,,,A- ' r' f r', , I yf ,. f+� :{^' nyf 1 Y - ♦ " •Y +.a •tw"r'• III///"' + ,.. ,i' - - , i - f. r ,'a` ' µ - " i + : + �� T' �!�,f -y:tea;' '~ r, 5 .•' e ' .. ± d _A ` rtP*' ^y f r ... '4, ,♦f N' -f..fit' .i. 'r 7 ,i} , T 4.: I. 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