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a- s THE COMMONWEALTH OF MASSACHUSETTS
BOARD- OF HEALTH
` Orin.........OF.......bR7—N 5LE
Appliration for UispooFal Works Tonitrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
2o-4D E ,_o T 36
cat n-Address or No.
O r Address
iD act
WW1 ...... .............'—` �..f�c...Air, -- .. ........Con
. /1 _.. ...........
ss` 0 f In tdl•er Address Q /+Q
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...........`................................Expansion Attic ( ) Garbage Grinder (><)
04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------___..............................................................................................................................................
Design Flow........... .!�� gallons per person per day. Total dail flow____----.33o gallons.
WC / !f 1 !/ 7.............. . !r
WSeptic Tank—Liquid capacity/-5200.gallons Length./.(1 6.. . Width__�._9..... Diameter... Depth... ..........
x Disposal Trench—No. ........-........ Width......:..:.........Total Length........ Total leaching area....`________------sq. ft.
Seepage Pit No.........1........... Diameter--------�z_.------- Depth below inlet... _•. ....... Total leaching area.38....sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) �"�Gu'°��S 4-1 5��+`E
'-' -28
Percolation Test Results Performed by.e�.D A ._ ...................`� � Rt 5'___ Date.-----._2Z..
Test Pit No. 1.4.2....minutes per inch Depth of Test Pit....9t..6...... Depth to ground water-----
1....
6_`...__.
I=, Test Pit No. 2.L._�__..minutes per inch Depth of Test Pit..... .._la____. Depth to ground water____---_..6._..____
a -••-------••-•----------•-••-•-•-•_.--- .
Description of Soil---• .'_ `.._�oA"!H f..c !! 6 jL--------------•--•-•----•.-•••--........._.........••-•--......------•----
w ----------------------24-Y,-_IT4"i----M �ivr �An6D
--••----•••-..._..-•-•-••-••••-•----•----•-••-••--•----•---•-----------------------•--•----•--•-••-------•••-•--------•-••••----...•---••••-----•----......•-•--•-•-•--••-••--•-------•-•-••••-••---•---
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 has be n issued b d f lth.
5
Sined--•-- --- ......-_ ... .. . ....._
�p Date
Application Approved By...... (..-1__ . ...L�t,�lrI'--7 --_
Date
Application Disapproved for the following reasons:_------------------------------------------------------------•-......----•-------.......... .........._..
---------------------•--------------....-•--•-----....---•------••---•--•--...-------------•----------------•••-•--•--•---••-•---•--••-••---•--•--•--•-------••-•--------•----••---•---•-•-----...._.__.
Date
PermitNo......................................................... Issued.......................................................
Date
C7 - c• 1 - 6r+�
No.........................•. ;,
.r
TjHE COM/M�ONNWEALTH OF MASSACHUSETTS
,
RD %FgMjj��
f
Applira#ion for Disposal Works Tonstrnrtinn Pumit
t Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
V ,at •
k:
1 Location-Address or Lot No.
..................
Address
W /UT... ..�0 �
- � ......................................................
Installer ••--•- •
Type of Building Address
Size Lot............................Sq.�,*t
V Dwelling No. of Bedrooms............................................Ex Expansion Attic
� g— P ( ) Garbage Grinder ( )
p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria
a' Othe es
Design Flow............._. ..._.._ gallons per pers p day. Tota , (flow............. '�______________ ons.
WSeptic Tank Liquid'caps ty.........•.gallons Length_........_..••.. Widtl -- Diameter----. Ile pth................
Disposal Trench— o. ............... Widt R ......:_.___.__ Total Length x p T gt ...Z3t <'__.. Total leaching area. ......sq. ft.
Seepage Pit No......................Diameter-------------------- Depth below inlet--------•-•----..-_-I g --sq. ft.
z Other Distribution box ( ) Dos'
Percolation Test Res ltsr Performed b 'ft)a*�3 )`�' , orFe,O R-$` Z14 V..95
{ .... Date.
----- ------
Test Pit No. 1.,e_p,......minutes per inch Depth of Test Pit - Depth to ground water..-fp �t..-.-.
Grq Test Pit No. 2................minutes per inch Depth of Test Pit.•-_-._._...__._.__. Depth to ground water-...._..._...__.._......
0 f�� ' -1 aomt-� `� >(�,,,.------•---•-•-•-•-•-------•-------------------------------------------------------------------------••---------------------------.-.--.-.-------
Description of`Soil_---•• -•---- ......-- •--•-•-•-----•••---- -•-•----
x
U I -- -------•--•------------- -----------------------•-----------------
�+ r , rr
r� •-•-•------------------------•--------•-----._...--•--••-••----.......----•----•-•------•-•-•---------•-•----------------•-------•-•-•-••••••--•---•------------°--•-----•---......-•------•-•--------•-
VNature 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 TITY-S 5 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.
_
---•---------•---------•---------i� ....-•--••---•----------------•-
........�/.......................... ........................................
t
Application Approved By..... Date
Application Disapproved for the following reasons-----------------------------------------------------
--•--•-•----•--•------•------•-•----•---...------•--••-••-------•----------•-----•-----•----•----•----••--•---•••--------------•--•------•----
Date
PermitNo••---_....•__......---•---•------•---------------•------• Issued...................................
-
r
Date
THE COMMONWEALTH OF MASSACHUSETTS£,.;:.
BOARD OF HEALTH
.....................................:....O F...................,.................................................................
( rdifir of (t lj anrr-
THIS ISFY a a wag constructed ( ) or Repaired
.� :
by -..... ......-• ------ ----.......-•--------•-------•----•........................ ( )
Installer
at.............................................................
-•
has been installed in accordancewith the provisions of / `/ The State Sanitary �og7y_d"bed in the
application for Disposal Works Construction Permit No......................................... dated-...------._.-----..-_-_-..---_..-_.....___.___.
THE ISSUANCE-or- THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL
. FUN; ION
SATISFACTORY.
= G-DATE.... ---
.. Inspector.--------
/G
-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH:
...........................................OF............ .Z
No......................... FEE........................
Disposal Vvrk5 Tau&n flan ' #
Permissionis hereby granted ................•--------•-------...----•--•-=••----.......................•••....... .........................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNO............. ....... StreetQ ------------
as shown on the application for Disposal Works ConstructioVP119
" No -•/,�Y:�, '.•••.-___•,____.____._
S • 7 ....................................
Board of Health
DATE.................
--
FORM 1255 HOSES & WARREN. INC., PUBLISHERS -
LOCATION SEWAGE PERMIT NO.
3Z 64C/e��'�
VILLAGE
INSTA�� LER'S NAME & ADDRESS s,
aCpw, e-s
B U I1 D E R OR OWN ER
1/J Jll C C7, al-le'lf;�'�'�.
' DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED �. _ '7
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EXISTING O - .Z4 LOAM AND
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LOT 30
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