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I / THE COMMONWEALTH OF MASSACHUSETTS ,:~~ _ ~J''''"'''''

r' )?J.pPI~~:~E::;:'!;:;:~~:~~~~.r~r'l ~~~) Application is hereby made for a Permit to Construct (v) or Repair ( ) an Individual Se~)lge "" " * ,\'

~~~~2 .. S.h.J:l.tes..b..y..r..Jf. ........ R.Q..!I.kL.................. . ...................... Lr .. t.. .......... _ ......................... ~~:~:~~:.:~~.~~"""" Location. Address 1> (l B o~t No. f II A

.......... g~w..j-f.g·i?!!:.!.!·o~~;f!:!1 ....... -........ -... -.-..... -...... ..J.-:. ..... : ...... J:l.z. .. A.ll;.._ Add'!:'l·~..t· ....... .L~Lt:'--.fi.:. .... ... X .......... ____ ....... _ ....... m .. '!:?tf.._. ___ . ___ .... _ ....... ___ ........................... . ... -...... 1l1..~~ ... : .. -.. 7.!1 ... -----.: .............................. -..

-~ -- A Type of Building Size Lot .. L_3J/:J. ___ __ .!:..~ Dwelling - No, of Bedrooms ____ .... ____ ... _b .......... _ ........ __ .... Expansion Attic ( ) Garbage Grinder (1lAO Other - Type of Building .. _____ ........ __ .. _ .. ______ No. of persons ______ ____ _ . __ . __ ._. __ ...... Showers ( ) - Cafeteria ( )

Other fixtures .... ........ ....... ___ .... ......... .. .... __ ........... ........... __ ...... ... .......... .. ..... ......... ____ . ___ . ______ . ___ ..... ... .................... . Design Flow ____ , _________ -?:~ __ .................. ",gaIlons per person per day. Total daily flow ____ ......... 2,U;>,.""""" .. _ ....... gallons, Septic Tank - Liquid capacitY-lQ.~_!l_gallons Length ___ ~ ___________ Width __ ..... "" ... " Diamcter..."" .. ______ . Dep~ .... ------.--,,- (5.~ Disposal Trench - No, "" __ J ____ ._. _____ Width ___ ;?,_' ______ __ .. __ Total Length . ..I£f ___ ..... Total leaching area __ _ !~#..!.sq. ft':1 (2.. Seepage Pit No .. ,, _________________ Diameter. ___ ,, ____ _____ ___ .. Depth below inlet .... ___ ............. Total leaching area. ... ,, ____ ,, __ .. _.sq. it,

~~~:~I~:~~i~::itO;~~~t~ v) Performe~~;i~~_~?~/f_~i--,, __ E~jJ.:_q.~_. _______ ._ .. _____ __ Date._J~ ... ! .. ?::.,.' .. !fL'-!. Test Pit No, LJ:?. __ .. _minutes per inch Depth of Test Pii... .. !::k.~ .... Depth to ground water ..... li., .... __ " .. Test Pit No, 2_ .. __ ... ___ ____ _ minutes per inch Depth of Test Pit.. ... .f.~ .. ~ .. ~· .. Depth to ground water. ___ LUn_e.. ....

Description of Soil_._~(JJi.tif":. ............. __ ....... ______ ._ ..... ______ .... __ . ____ ... ....... __ ..... _______ .... ...... ....... __ .............. .......... __ ......... __ . __ . __ ..

Nature of Repairs or Alterations - Answer when applicable ____ .................... __ ..... __ ..... __ ...... __ ... _ .. __ .... __ ............ _ ..... _ .... ____ .... __

Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with

the prO\'isiolls of ?ITLE 5 of the State Sanitary Cod - The undersigned further agrees not to place the system in operation until a Certificate of Compliance has e by the of health.

V'~~-.......... -... -................. -......... ._~I2 .. !.L._ . ... -... -5/1'~?(f. ......... Application Approved By._ .......... !... _!kt'V~L4£N.:i;j4 .. -----.... ---- ................................. .

Date

Application Disapproved lor the fol/owi1lg reasons.- ..... _ .... __ _ ............ __ .... _._ ............................... ____ ...... __ .. _._ ............ __ ............... .

Permit No. __ .... c;tJ::LL ........................ _ ... . Issuect.· .. ···-· .. -·}JJtt-..IftdlE .......

THE COMMONWEALTH OF MASSACHUSETTS

BOARD OF HEALTH

, .. _______ . ___ OF .. __

IDrrtiftratr of IDnmplianrr THIS IS TO CERTIFY. That the Ind:vidual Sewage Disposal System constructed ( ) or Repaired ( )

by ............... _____ .... ................................................................... __ _ ....... . _______ ._ ... _ .. _ ..... _. __ .. _ ..... _ .... _ .................. _. ___ .. __ ._._ ...................... .. Installer

at ...... ____ ....... ____ ... ..... ....... __ ...... __ ...... ____ .. __ ...... ______ . ___ . _____ ....... ___ ...... .. __ ... __ ................. .. ..... __ ... ..... ........................ __ ............................. . has been inst~lled in accordance with the provisions of TIT ~ 5 of The State Sanit;:;. ry Code as described in the application for Disposal Works Construction Permit No. ________ ____ .. __ . __ ____ . ___________ ..... dated. _. ______ " ____ ,, __ """ ____ ,, __ .. __ ,,. __ ____ .

THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.

DA TK_ ... _ ..... _ ... _._ .. ____ .. __ ._.". __ ..... ___ . ___ .. _ .. _ .. _ ........ __ ._ .... __ ..... Inspector ......................... _ ............ _ ........................................... ..


NO ... 2!i.-'-::'l ... (.. .--;----> BOARD A HEALTH

...... J.f?WtJ ... ... OF_ ..... ..... 'J1:1..<!5..c _" ... ... "."" .. F"E.r~ .......... mi.5pn!ijtl IInrk.5 IDnn.5trurtinn J'rrmit

Permission is hereby granted. ___ r.~'::.&_~_+J/...t0.'f.~_ ...... _= .. ,E(;_~_."' .............. ____ ...... _. ____ .... _ ......... _

::::::~t!~E,(~£':~::~~~!~:~~;E~!!:=: ~_~D" ~. DA TE" ...... ____ ____ ....... " ... __________ ...... ______ ....... __ .... ____ ._ ......

FORM 1255 HOBBS Be WARREN. INC .. PUBLISHERS

•

,

. -

-~

'No, ___ _


BOA.RD OF HEALTH -rowrL ...... oF2}h1 . lu~l~~.r d ..................... d .......... _.

Application is hereby made for a Permit to Constouct System at:

c3 {, 1 .S}HU:e.sjHI..r.:Jj.n._nRp..!!.d ..... _ .. _. __ 3 Lcc~~:::-n· .\ .:!:re5S

__ P..(l..IdIL.fu.~.r.U;.J:l.#.h. ..................... _ ..... __ Ow::e: Address

-_.-•.... __ . __ .... _ .... _ .................... _-_ ........... _ ...........•.... _-_.... --_ ......... __ ....•.•................... _---.......... -_ ... _--_ ....................• -._------_ .. l llsta:ler Address . A ..

Type of Building Size. Lot..L3:i.l ...... ~ .Sq . leet Dwelling- Xo. 0; Becirooms ................ b ......................... Expansion Attic ( ) Garbage Grinder ( ) Other - Type of Buildi:lg ............................ No: of persons ............................ Showers ( ) - Cafeteria ( )

Other fixtures ................................................... .................................... .............................................................. . Design F1ow .............. :?.~ ................... .. .. gallons per person per day. Total dai ly flow ............. 2.Z0 ...................... gallons. Septic Tank - Liquid capacity/u.,UI.gallons Length ... : ............ Width ................ Diameter ................ D~pth................ ./ Dispcsal Trench - Xo ....... J ............ \\·idth ... ;1,.' ............ Total Length . ..I$.'-. ....... Total leaching are:L ... ~';'#~.sq. ft. ~~ ~ S eepage Pit ;\0 ........ .... ......... Diameter ........... ___ ...... Dct:nh helo\," inlet.. __ ................ Total leaching area .................. sq. it. Other Distribution box ( v) Dosing t~k () F, . Percolation Test Results Performed by .. ..... C(~Cfe.r..!.(f,. ..... -:~~iL:.Q.? ..................... Date..J.~ ... L:ZO .... I .. ':I.$..'!..

Test Pit :\0. L.l:5.: ...... minutes per inch Depth of Test PiL. .. !'± .. ~ ..... Depth to ground water .... .1.L ......... . Test Pit )\0. 2 ................ minutes per inch Depth of Test Pit ...... f.: .. !i .. .'.~ . Depth to ground water.. .. .J:1 .m.~ ... .

Description of Soil ... £"d~;:~;:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.-.. .-.. .-.-.-:.-.... .-...... .-:.-.. .-...... .-.-.-.-........ .-.-.-.-.. .-.. :.-.. :.~.-.~:.-:.-.-.-.~.-:

Nature of Repairs or Alterations - Answer when applicable ................................................................................ _ .... _ ..... .

Agreement: The undersigned agrees to install the aforedescribed Individual Sew~ge Disposal System in accord:mce with

the provisions oi ':'ITl...S 5 oj the State Sanitary Code - rhe undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health.

Signed. .............. _ ............................................... _.................. . ....................... ___ _ D ... :c

Application Approved By .............................................. __ ................. _ ........................... _ Due

Application Disapproved for the fol1tr .. dng reasons: ............................................................................... _ ............... __ .. ____ _

Permit No ................. _ .... _ .. __ .. _ ... _ .... _. __ Issued.._._ ....... _ ............. _ ...... _._._. __ Oat<


BOARD OF HEALTH

............. ..................... .. .... .. OF ............ ................................. ........ .............................. .

(!1rrtiftratr of (!1ompliattrr THIS IS TO CERTIFY, That the ImEvidual Sewage Disposal Sjstcm constructed ( ) or Repaired ( )

by_ .. __ .. _._ ... __ ... _ ..................... _ ...... _ .................................... .............. _ .......................... _ .................. _ ......... ___ ... _____ _ InSfJ.i:er

at..._ .......................................................................................................................................................................................... .... _ has been inst,i1ed in accorbl1ce ",iti, the pro\·isioI15 of -:: .:-:..:: 5 of The State Sanit~,ry Code as described in the application ior Di~posa t \\'orks Constr:lct ion Permit Xo. ........................................ d:tted ......... ....... ................. .

THE ISSUANCE OF THIS CERT:FICATE SHAll NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.

DA TE. ............ __ .•................... : ....................................... _ Inspector .................................................................... _ ............. .

"

SHUTESBURY ROAD I!>() •

/. '343 A<.:-

H()U.sE

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PLAN Sf/Oh/IAIC

S[,IAIAGE DISPOSAL

For: Pawl !5q.jQ_t')C'htth P,O. B .. >t S2J

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