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i\pplicutiou for 1]iisposul morks (!tottstruttiou Jrr\tt.; 1~8 R.S. 1

THE COMMONWEALTH OF MASSACHUSETTS

-:. ~ Application is hereby made for a Permit to Construct (I---1Or Repair ( ) an Individual s"wa is ,,~

',.1.. *" System at: ","""1' ¥ t"

.................. S.iudIe.I:.J.t.t.f:-t. ......... KO'fi.d........... . ....................................... (.~ ............................... ~~~.~:~.~~:.~~:.~~.'.' .. .

:::::'!!£.~~~~r!~Z;;'::a.:t:?j:::::::::::::::: :~/?:.:~~TL~_f:z::;!;;~nr t Installer Address

Type of Building Size Lot....~.'.81 ... A'c .. S~ Dwelling - No. of Bedrooms ............... 'f .......................... Expansion Attic ( ) Garbage Grinder (-+-4-0 Other - Type of Building ............................ No. of persons ............................ Showers ( ) - Cnfeteria ( )

Other fixtures ..................................................................................................................................................... . Design Flow .................... 5.S ............... gallons per person per day. Total daily flow ......... 'if9 .......................... gallons. Septic Tnnk~!tiquid capacityJ.CI.Q.Q.gallons Length ................ Width ........ , ....... Diameter ................ Depth .............. .. Disposal ~- No .......... .1 ....... Width ..... ~.'t.' ........ Total Length ....... :'i~ ....... Total leaching area ... .IIL3.2.. .. sq. ft. Seepage P it NO .......... .. h .. h .. . Diameter ............. h ..... Depth below inlet... ................. Total leaching area .................. sq. it. Other Distribution box ( L.1' Dosing tank ( ) -1-Percolation Test Results Performed bYh ... /T~dt:r.1C.i. .5h .1/2,$, ..................... Date .. .l?e.t:...~ .. 2. .. .!2.4.3

Test Pit :\'0. l ..ltL!!.1.minutes per inch Depth of Test Pit... ...... 7 .. ' .... Depth to ground water ..... .J.t.a?1..e .. h

Test Pit No. 2 ................ minutes per inch Depth of Test Pit... ................. Depth to ground water. ................... h ..

Description of Soil ......... £..i.t:clu:s.:e.:a::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.'.'.'.'.'" ............................................................................................... .

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 ?ITLE 5 or the State Sanitary' Code - The undersigned urther agrees not to place the system in

::~":~:::'~' ",,';;:~'~~~~;--:i1iil~ ~O··t Date

Application DisapprOVed lor the lollowi>lg reasons . .............................................................................................. ................. .

D,,-~-3

Permit No ...... .cf::: ........................................ .. Issued. ......... d ... JJ...2::::~ .......... .. Date

THE COMMONWEALTH OF MASSACHUSETTS

BOARD OF HEALTH

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

C!rrrttficutr of (!tompliaucr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )

by ............................................................................................ ...................................................................................................... .. Installer

at .................................................................................................................................................................................................... . has been inst~lled in accordance with the provisions of T 1:':' i.E 5 of The State Sanitary Code as described in the application for Disposal \Vorks Construction Permit 'Ko. ......................... ............... dated ............ .................................. ..

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

DA TE. .............................................................................. . Inspector ......................................... .......................................... .

THE COMMONWEALTH OF MASSACHUSETTS

FORM 1255 H088S & WARREN. INC .. PUBLISHERS

• -- -

No ................ _....... FEB ............ L.:J. I.~l.!.:.LI,. 1 " . - r:- 1/

THE COMMONWEALTH OF MASSACHUSETTS , .... \ • • ~ . .'. , . , ,' .~: . ~/~~, ... ~ • • ~ (0 ·' v", "

BOARD OF HEALTH l>' Jij/':"J;\ .. 7 O(.(fn OF .... AmheLS t ................. ...... ..... ..... f:'~ ~· ri·J· . ~ ~ ( ~~:~ :: ,-; Ak '., , ~

i\ppliraHon for iJinposul llIorliS QIousITurtion .ll~net\ L. ~8 R.S. ) /

Application is hereby made for a Permit to Construct (~r Repair ( ) an IndlVldual S!.:wa~.J2.!sp'~/ ", System at: ~~~'" ~~ ~:.,;. * \\\ ...... -·····~·X··-SJu,Li~~;;.1.i~;;······R.O'fLd. ........ - ···:········/ii············;i··!;;~L;;"jj~·-······--··p;~·:~;.~~:.;~.'.~;'" f/ ' ._ .. L':l.lC:/1.at:.L .. DLU.m.a.Y.1 ............................... _... .J.irJ ........ 'II.ns.e.k./J..(;L.1:ilf-n······ .. 7i)..tlM/LL2'" 1 t n

Owner Address,-.. <...-<).

Installer A ddress

T ype of Building . Size Lot .... ~!.8? .. .4C .. S~ Dwelling - No. of Bedrooms ............... 'f .......................... Expansion Attic ( . ) Garbage Grinder ( -}- It-o Other - TyPe o[ Building ............................ No. o[ persons ............................ Showers ( ) - Cafeteria ( )

Other fixtures ..................................................................................................................................................... . Design Flow ....... =.505.= ............... gallons per person per day. Total daily Row .......... 1.i.9 .......................... gallons. Septic T:;;.~.!riquid capacityJ.Qqg.gallons Length ................ Width ................ Diameter.. .............. Depth ............... . Disposal I . \"'- Xo .......... 1. ....... Width ..... t:,'f..'. ....... Toial Length ...... .:i2 ....... Total leaching area .. ..i!i...:> .~ .. sq. It. Seepage Pit Xo ........ ............. Diameter .. _ ... ____ ._._ .... __ Depth below in!ec.. __ ............... T otal leaching area .......... __ ...... sq. ft. ~ .

Other Distribution box ( v1 Dosing tank () --I_ " Percolation T.st R.sults . Performed bv ..... ./5:.t:.dr:r.J:C..K.E.l.. .1.(.l~ ..................... Dat~ .. ];>e.c...ft .. 2. .. Iy'#..3

T.st Pit :-':0. 1../IL!!.1 .. minutes per i';ch Depth of T.st Pit... ...... 7-. .' ..... Depth to ground water ...... I1,rn.t:, ... . Test Pit 1'\0. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ................ __ ..... .

Description of Soil ......... En:clo:s.:-e:a::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::." ... '.'.'.'.':.': .. ' ... '::::.'.'.' .. ::::.'.'.': .. :.' .... '.':: ...... :.::: ........ : .... .

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

Agre.ment: The undersigned agrees to install the aforedcscribed IndiviciuJ.I Sewage Disposal SYstem in accord::mce with

the prQ\'isions oi ~ITr..::: 5 or the State Sanitary Code - The undersigned further agrees ~ot to place the system in operation until a Certiricate of Compliance has been issued by the board of health.

Signed.................................................................................. .... . .......................... _ ... . Date

Application Approved By ................................................................................................. . Date

Application Disapproved for the follo'1Villg reasons: .................................................... ................................... ......................•.•

Date

Permit No ....................................................... _ Issued. ...................................................... . Oat,

THE COMMONWEALTH OF MASSACHUSETTS

BOARD OF HEALTH

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

QIl'rttfirah> of <llompliunu THIS IS TO CERTIFY. Tbat the l ",i:,·idual Sewage Disposal System constructed ( ) or Repaired ( )

by ..................... .................................................................. ........................................................................................................... _ l nst:d ler

at ........................ .. ............ ......................................................... ..... ................................................................................................ . has heen it1st:lllcd in aCl'ord:l.!lCl' wi t il the prc)\'i:; j()11:-' of .:::.~~ 5 or The S ta te S:1nit:-,ry C·)d<.':lS dc.:;cribcd in the application for .Oi:-;p0::':1l \\'ork:-; Con:\fr~h·tion Pl'r1llit ~o.. . ................... . ...... . ... . ..... . . d:lt('<i . . .. ............. ............. ....... ..

THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANUE "HAT THE SYSTEM WILL FUNCTION SATISFACTORY.

DATE ............................................ , .................................. . Inspcctor ............ ... ... ... ....... ........ .............. ......... . ;c ................ . .... .

Pt.RC.OL~'T\ON T£.5T LOc..~'T\ON

FOR: MIC.I-IAEL BULMAN BY: FRt:.DE.R\CK FlL\OS

510 M uN SE LL ROA\:> FeGRuAR'C 19<05

BE LC I.(G:RTOWN, MASS. SC~La" 1" = 100'

A.-r: .5HU-rES~UR'< RD.) AMHERST. MAss. - AM't-\t.RST BUILOI"-lC,CO.

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ALL MATERIAI.S AND C.oIllSTRUCTID N

\NILL B.:: IN Ac..CoROANC.e: WIT/-i

COMM.. OJ:' MASS. D.E.Q.E. STATE.

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