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C4�' -�4__ THE COMMONWEALTH OF MASSACHUSETTS l��j_
BOARD OF HEALTH
I/A
...........OF..... .. . .,6.0."STMLCG�.... .............
I pphration for Dispaiial iYarkg Tmitrurtion ramit
Application is her made for a P -mit to Con trucib(K) or Repair an Individual Sewage Disposal
System at:
R.... I.Ldr.... ...............LCq...... �!Ilfe.........-----_-------
..... ......
Location-
..... ..... . . .... ... ....... &..................
caner Address
............... .. ........ ...i:;
.... ..... . . .... ...L .. ....... ....... . . . ....................... ......
Installer----------------- _r. 15 Address
U Type of Building Size Lot.Z'A__-_A_'S7...Sq. feet
Dwelling—No. of Bedrooms.....3..................................Expansion Attic (1,1P Garbage Grinder Yips
a4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow......16��.....t 5-C>_14------gallons per person per day. Total daily flow......A.!��.......................gallons.
94 Septic Tank—Liquid capacity.ISUDgallons Length.�716.. WidthS=15.. Diameter________________ Depth,5;.:_-.A....
Disposal Trench—No..................... Width_.._................ Total Length_.................._ Total leaching area...................sq. ft.
Seepage Pit No-_-_--------------- Diameter....I-A--!------- Depth below inlet....5,-57..... Total leaching area...50&.sq. ft.
in tank Z Other Distribution box Dos
aa
Percolation Test Results Performed .......... Date................... Z:1
�4
1.4 Test Pit No. I...4Z....minutes per inch Depth of Test Pit...VV%.5..I--- Depth to ground water-JR...
f14 Test Pit No. 2................minutes per inch Depth of Test Pit..__...._....____._. Depth to ground water---------------------
P4 ------- ...............................
........... --------------t -------------*-----------------*--------------------------------------------------------- . _-,*............
0 Description of Soil....... 41 .6 .....................
...........6A .............................
........................................................................................................................................................................................................
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 TL I 1=4 5 of the State Sanitary Code— The undersigned f e ag e n pl e the system in
operation until a Certificate of Compliance has issued bo d of t
Sign( . ....................................................... ..................... ................................
ApplicationApproved By...................................................... ...... ......... ------------—--------
_Q� 10itz Date
�11o_win—grea_reasons:---
Application Disappr6veid"for W ...........................................................................................................
..................................................................................................................................................................... ................................
Date
JD/,--
.... . ...... ..-•------
Permit No..........R.0.......Y----------------- ... ... k�� Issued......... ..............
�' Date
t OA kp 1 g°z
THE COMMONWEALTH OF MASSACHUSETTS ,l
BOARD OF HEALTH
- ------- —------------------.....OF...... C?.1-: .. -E ► �-
Applirtation for UiiposFal Works Tonitrnrtion ramit
Application is hereby' for a P rmit to Co sir �( or Repair ( ) an Individual Sewage Disposal
System at: GtJ�L L{ i�°� 1co S
�t......L a�. �.t=a i2.:� LA�.�_1 .._.�,.�t�1 u�C�J 9 C l_.��:_... ................ ............. 1 ..
• Locatiot - dres --( (— t , 7'^
...................... S........"_.._"_. ..__......�j�_.___,_�_1'_�•___-t�7ti�'7t ;-- •-----•-Cs•.......................�1 4����.a�^1.1�.�-ai.��V..��d�L......
Owner t_ j Address l
W1`_......._... .......................... .... ..................................................... 4-�.c.
Installer ' Address
U Type of Building � �� Size Lot---ZA_ �? _..Sq. feet
Dwelling—No. of Bedrooms......3.................................Expansion Attic ( Ij c,> Garbage Grinder (`/tt 5
`4 Other—Type of Building No. of persons............................ Showers T
a YP g ---•-----•----------•--•---• P ( ) — Cafeteria ( )
dOther fixtures -------------------------------------------•-----------••-•---------------•---------•.
W Design Flow......`? ._.. ��..�'1.....gallons per person per day. Total daily flow__......Q► `�.......................gallons.
WSeptic Tank—Liquid capacity.I allons Length._NP-6. Width-5.-Z. Diameter________________ Depth_,=_��__.
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...............__...sq. ft.
> Seepage Pit No----_--------------- Diameter......t,�......... Depth below inlet..... Total leaching area...3..0 sq. ft.
Z Other Distribution box (\/ s Dosin tank
'-' Percolation Test Results Performed by._ > 't :.. '?.'.� '�� ` o ��
W Date
Test Pit No. I----- `'�-__-minutes per inch Depth of Test Pit-___- 2.. Depth to ground water_.!4 6�:E�_!
rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W •------------------------------- -----•-•---•...-•--------...- ---------•--•---------_....-•------------....-----------.----------••---.-----
D Description of Soil........D--" �_ Lpa.�n. ._��4��3 �?I�- Z j a Z�SC ....................
v ------•--- 1- =�` � tL�!> �...-LS .-" I k ....... .i�ka �.. _
W
UNature 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 has e5s4boar health.j a
Sined.............................................................. ................... ••-
'� Date
Application Approved BY - 1 [ ••----- -•--•---
(� /
Application Disapproved for the following reasons:............................................9..Q a
........°vl��[�6
D e
-••- ------�---------
ate
Permit No. �6 Issued.....-•-••- �I_�_ !/
/ Date `
C. �� I�l
THE COMMONWEALTH OF MASSACHUSETTS
OARDOf EA
................. . ... ....OF..........U.J. ...................... .�' '.......
TrrtifirFatle of Tontpliatta
THIS IS C RTIFY, hat the Individual 4Sewge Disposal System constructed ( ) or Repairedby.................. ....�....-•-- -- -
er v t
at......................................................... •-•-------------� � , -ci-
-----•-
has been installed in accordance with the provisions of TIE 50
Th S tok
tary Code as described m the
��
application for Disposal Works Construction Permit No.. .. ed_....._._._ .____. . '
�j ..............`
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE COITRIKE %A'GT A� THE
SYSTEM WILL FUNCTION 17i'7
TORY.
DATE.................
...........•-•----.. . •--•------------- Inspector........................ ............. ----------------.......................
A .. ('2' , — �$ THE COMMONWEALTH OF MASSACHUSETTS
BOARD
..._....- G.._ .................. ...OF.................... .l.v! .�
�-
No......................... FEE..... .,,,..
Dioposal Works Tons#rurtion Uppr t r�/
Permissio jy hereby granted............................ ...........A L j
to Construct ( or Repair ) an Individual Sewage Disposal System
at No.............
t,� -------t-7--------- _JWw:�-b-�,� _... ( ,;-------; ��----
Street
as shown on the application for Disposal Works Construction Permit N8 - .�..�. ... Dated.....io-fiole). .•-
-----•----------••------------------------ -,-•---••• ---- 3--•`r ----•-------•-•--.-.-.---•----
DATE.............. .. .........................................r ... Eoa e x h
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PETER
RICHARD : a, s
o` SULLIVAN
BAXTER H No. 29733
No.24,046
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ICHARD PETER U
A a` a SULLIVAN �
BAXTER -41
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