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HomeMy WebLinkAboutMiscellaneous - 76 BOXFORD STREET 4/30/2018 (2)R J. 7 16 lb MAP # ivG US ` 'Q PARCEL CONSTRUCJ �� G�G7v:tiAo sr HAS PLAN REVIEW FEE BEEN PAID?` YES NO PLAN APPROVAL: DATE ?/ � �/ APP. BY DESIGNER: <GT�yE - ox50 PLAN DATE (O o2 CONDITIONS -4- 1'42/r '42/r WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER WELL TESTS:! 4 PLUMBING SIGNOFF a COMMENTS: Y FORM U APPROVAL: ,W' DATE ISSUED CONDITIONS: FINAL APPROVAL: CHEMICAL DATE APPROVED BACTERIA I DATE APPROVED BACTERIA II DATE APPROVED WIRING SIGNOFF APPROVAL TO ISSUE YES NO BY ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: 4e. ra sr r t f MAP # # PARCEL # STREET Sby ke, 6L V 1.0 CONSTRUCTION APPROYAL HAS PLAN REVIEW FEE BEEN PAID?f YES NO PLAN APPROVAL: DATE / 1p 9 APP. BY ZdD DESIGNER: �GTEyE -D1U)e 5d PLAN DATE (O lal7,6 CONDITIONS r r _ /l,z, (4, e-,,1 - CL—c- e-- n `F c: - w 444 WgER SUPPLY: TOWN WELL WELL PERMIT DRILLER WELL TESTS:' CHEMICAL DATE APPROVED PLUMBING SIGNOFF COMMENTS: FORM U APPROVAL: Jj, DATE ISSUED CONDITIONS: FINAL APPROVAL: BACTERIA I DATE APPROVED BACTERIA II DATE APPROVED WIRING SIGNOFF APPROVAL TO ISSUE YES NO ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? TYPE OF CONSTRUCTION: NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW CONDITIONS OF APPROVAL (FROM FORM U) YES NO NEW REPAIR YES NO YES NO ISSUANCE OF DWC PERMITYES NO DWC PERMIT PAID? C YES NO DWC PERMIT NO . s INSTALLER: BEGIN INSPECTION OESNO: EVAVATION INSPECTION: NEEDED: CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES: APPROVAL atO BACKFILL: DATE: A//9' 7 BY __- FINAL GRADING APPROVAL: DATE FINAL CONSTRUCTION APPROVAL: DATE: < 3�1 BY North Andover Board of Assessors Public Access ,ioR7y �eNuse Return to the Home page click on logo New Search Sales Town of North Andover Roard,of Assessors. Parcel ID: 210/104.D-0035-0000.0 SKETCH ick on Sketch to Enlarge Summary d` Residence Detached Stru re Condo / Commercial Comparabl Sal Page 1 of 1 Property Record Card Community: North Andover PHOTO Location: 76 BOXFORD STREET Owner Name: BORYS, STEPHEN W KATHLEEN A BORYS Owner Address: 76 BOXFORD STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 5 - 5 Land Area: 1.01 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 3130 sqft ASSESSMENTS Total Value: 12,.:1.1:_ _ — . -- - CPT®" Code 90734 •CPT is a registered trademark http://csc-i of the American Medical Association. MKT9872-1 CURRENT YEAR 521,200 `'00 tMenactra, MeningocOccall (Groups A C.Y and W-1351 Polysacchande Diphtheria Toxord Conjugate Vacdne PREVIOUS YEAR 472,400 290,300 182,100 LE Sale Date: 12/31/1972 Grantor: Page: 0739 348 7/11/2007 VwperaC�yCa �3ena � 1%o. CO GpC®5 Code d ms �s�on .pPT menc ct she P �9a�2.1 M North Andover Board of Assessors Public Access ,roRYy h y Return to the Home page click on logo New Search Sales Parcel ID: 210/104.D-0035-0000.0 SKETCH. on Sketch to Enlarge Summary Residence Detached Stru re %- A, Condo / Commercial / Comparabl Sal V i Page 1 of 1 Property Record Card Community: North Andover PHOTO Location: 76 BOXFORD STREET Owner Name: BORYS, STEPHEN W KATHLEEN A BORYS Owner Address: 76 BOXFORD STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 5 - 5 Land Area: 1.01 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 3130 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 521,200 472,400 Building Value: 313,300 290,300 Land Value: 207,900 182,100 Market Land Value: 207,900 Chapter Land Value: LATEST SALE Sale Price: 0 Sale Date: 12/31/1972 Arms Length Sale Code: N -NO -OTHER Grantor: Cert Doc: Book: 01221 Page: 0739 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3&Linkld=990348 7/11/2007 . .y,jn.yr �� �-, •Icy,�ll�:'yV/�'1'J:,ryh'.'•�:f'r.l'i•r`i`A'ki'yj'��!�'�Yi!•i_'.... j;):� ).� 1.^: 1., n3+,�'!I:., y�•'. 1J'`•Y'.iit'i: J11 ,ilr;1: •Ari•::. r1.,d„ ar.; ,..:'.;;Y;, r''•' EP: has provided this form for use by local .: be:ubinitted to tha.local'Soard of Health or, .Ai Fac111 lnfo�ri��tion . ., ....• :'." : ''' % •'' ' Gallons TYpe pf.system;', ❑ Cesspool(s) �4rW n filunfl out :1.. 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Lij J _J J ri CV Q w GC > Uce Z d OQ U J � Z+•T; tib iii ob CL V) vz gr Cj- J U -i CL V) _0 F— 4 No. FORM 11 - SOIL EVALUATOR FORItt Page 1 of 3 Date: Commonwealth of Massachusetts /✓O Ay lb Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Performed By: S ,eS _Date: RIZ91 Witnessed By: 2s Aea,"s. /l ��1-i/ -17 �`/ Tel / Newconstruction El Repair Office Review Published Soil Survey Available: No ❑ Yes 4 Year Published Publication Scale -166 7 Soil Map Unit Drainage Class �. Soil Limitations-1 iterations A .. .... - Surficial Geologic Report Available: No LJ Yes El Year Published Publicatic:i Scale GeologicMaterial (Map Unit).......................................................................................................................... ............................ Landform� ......., ... ..... ._.... ...............'..:................................................. ,............... ...... .............................. � ._.._.................... Flood Insurance Rate Map: Above 500 year flood boundary No ❑ Yes L� Within 500 year flood boundary No Yes ❑ Within 100 year flood boundary No 3Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ................. ................. :......................................... _...................... Wetlands Conservancy Program Map (map unit)................................................................................................_ Current Water Resource Conditions (USGS): Month Range :Above Normal ❑Normal ❑Below Normal ❑ Other References Revitwed: o1P DW APPROVED FORM • 12/09195 FORM 11 - SOIL EVALUATOR FORM Rage Z of 3 Location Address or Lot No. % % Oft -site Review Deep Hole Number Z- Date: cIZ91G Time: ',Weather Location (identify on site plan) 4 -ex— Land Use =� Slope M !� Surface Stones "4b Vegetation pQ,4 Landform YKB✓cwi�t� ` Position on landscape (sketchon the back) Distances from: Open Water Body �6&J feet Drainage way '?M feet Possible Wet Atea ?/Do : feet Property Line feet Drinking .Water WellOther DEEP OBSERVATION HOLE LOG' Depth from Surface (lnchis7- . Soil Horizon Soil Texture IUSOAI Soil Color ('Munsell) Soil Mottling Other Structure, Stones, Boulders, Consistency, % Gravel) 13W �s L ✓ ��v�1 enr .c-5 /V Parent Material (geologic) __ Z Z-4— Depthto9edrock: Death to Groundwater: Standing Water in the Hole: Weeping from Pit Face: )estimated Seasonal High Ground Water: nz DEP APPROVED FORM - 12/07/95 817__932 --761s P.,02 t'.=w �4 0 -PERCOLATI S MT: -------------------------------------- ................... FOR -4 2 Location Addrets or Lot No. 77 ..,COMMONWEALTH OF MASSACHUSETTS Massachusetts Percolation Test Time: �:C) a Ite: —1,2_ ql,' Observation Hole Depth of Pere Start Pre-soak ' �. Ski _ . { _ End Pre-soak Time at 1.2" - Time at 9" a 6" Time at 6 Time ..Time As" -6") Rate Min./Inch Minimum of 1 percolation test must be performed in both the primary area AND. reserve area. Site Passed i Site Failed ❑. ............... j Performed By: By:` Comments: iiDIP AFMOYW YORK - U'"IS . ... ... ... .. ... I . ................... .... ... ..... ........ e � FORM 1I.- SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. 7? 494�Z -A4 Determination ,for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole inches ❑pth weeping from side of observation hole inches. YDepth to soil. mottles inches Ah,()Z---7- F:30A)o ❑ Ground water adjustment ...... feet Index Well Number ...... Reading Date . _ _. Index well level .... ... -. Adjustment factor Adjusted ground water level Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in al areas. observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on 11157 (date) I have passed the soil. evaluator examination approved by the Depa tment of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. IL Signature Date 1WDEP APPROVED FORM • 12/07/9s I ', � ... �. ,ti , . � �> ,\ � ... �. ,ti , Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director June 16, 1997 Steve D'Urso 22 Lilly Pond Road Boxford, MA 01921 RE: 77 Boxford Street ,!D This is to inform your that the proposed plans for the site referenced above have been disapproved for the following reasons. 1. Elevation of perc test missing. (N.A. 6.02j) 2. All pipe to be schedule 40. (NA 18.15) 3. Manhole to within 6" of grde missing on tank. (310 CMR 15.228(2)) 4. Scale on site plan not stated. 5. No wetlands disclaimer. (NA 6.02o) 6. Bed size less than 900 square feet. (NA 2.14(1)) 7. Trenches to be used when possible. Please explain why bed selected. (310 CMR 15.240(6)) 8. Suspect there are more than 4 bedrooms because of in-law apartment, therefore insufficient leaching. If you have any questions, please do not hesitate to call the Board of Health office at the number below. Sincerely, _Sandra Starr, R.S. Health Administrator cc: Wm. Scott, Dir. CD&S File Steven Borys BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover, Massachusetts NORT#1 BOARD OF HEALTH Of 1 O tT�io ,e 6 OL c F 1- A '',s�,•,o0. DISPOSAL WORKS CONSTRUCTION PERMIT SACMUSE Applicant G�:✓'✓`cpG / i�-e,-S�t-. NAME ADDRESS TELEPHONE Site Location 7t� /3dx 'j— -�� Permission is hereby granted to Construct ( ) or Repair( an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S. No. Fee 7J MAP AND PARCEL / ADDRESS l 13 cyi� OWNER dte (�� a �j�'A SIZE OF LOT IN SQUARE FEET O S— # BEDROOMS SEPTIC SYSTEM LOCATION�/� (For example, FRONT YARD SOUTHEAST CO"R) FINAL GRADING DATE �' q " q 7 AS BUILT PLAN IN�FILE? 1 S INSTALLER DWC PERMIT DATE CERTIFICATE OF COMPLIANCE DATE ENGINEER Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH November 12 9 97 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired by George Henderson INSTALLER at 76 Boxford Street SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 939 dated August 6 19 97 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: J CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTALLER: le �� }, s Za SIGNATURE:.��.� I /L .,_ TELEPHONE# G G �S-8 '9S— CHECK 9S CHECK ONE: REPAIR: Z__, NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes �� No Foundation As -Built? Yes No Approval �f Date: ANDOVER SEPTIC 47 Railroad street ROTO -RAM Nature of Service El NIC NIC (978) 475-2593 Bradford, MA 01835 (978) 452-9022 0 EmergeEmergeencyncs F.99 Night .Date of Service PAY FROM THIS BILL Customer Name: 13P� % f Service Location: —y I Phone: / (J Contact: Billing Address: City: Special instructions Per: A■VOKA ❑ Incomplete' Reason: Septic Tank Pumping and Cleaning "Done the Right Way" Emergency 24 Hour Service - 7 Days a Week Services Rendered Vacuum Pumping Observations Drain Cleaning 'SepOc Tank ❑ Good Condition ❑ Main Line ❑ Drywall ❑ Leechfieid Runback ❑ Toilet Howl ❑ Leech Pit / Overflow ❑ Riding High ❑ Kitchen Sink 1:1 D -Box (liquid level} ❑ Bathtub / Shower O Pump Chamber ❑ Full to Cover ❑ Vanity ❑ Grease Trap ❑ Excessive Solids ❑ Floor Oram El Catch Basin Top /Bottom O Yard Drain ❑ Portable Toilet ❑Use No Powdered Soap C] Vent ❑ Other } El Heavy Grease ❑ Sewer Jet Qty: / E3 Roots ❑ Other Size:❑ Suggest Electric Footage: C1Under 1000 gallonsgallons❑ 1500 gallons Rootering 4000 gals [32000 gallons El3000 gallons 11lon C3 Van Called ❑ 5000 gagons ❑ other . C3 Other Misc. O Digging Charge ❑ Backhoe ❑ Inspection hrL O Location ❑ Consultation O Certification: P/F ❑ Service Call ❑ Estimate Reason: ❑ Labor ❑ Portable Toilet Rental ❑ Pump Repair ❑ Waiting Time ❑ Baffle ❑ Repair ' DJ'gging Charge Is Per Driver ❑ Chemical Treatment ®iscretion ❑ Other DescrigUon of Work Recommendations Terms of Payment Parts Vacuum Pumping Drain Cleaning NET 15 DAYS Tax Yr. Month Yr. Month Discount Terms & Conditions D Cash ❑ Check O Credit I - Not responsible for damage Tota) mag beyond curb line. 3. 1.5%per month will be charged to accounts past due. 2. All complaints shall be reported within 48 hours. 4. The purchaser agrees to pay all coat of collection. I _ Town of North Andover, Massachusetts Form No. 2 C� 140DTq, BOARD OF HEALTH o �� �y � • s DESIGN APPROVAL FOR CNOSEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant-e-��-°^_ Test No. Site Location � } Reference Plans and Specs._, C116 X? ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee CHAIR AN, BOARD OF HEALTH Site System Permit No. 939 uc7'/010 /ot% c�/Z � 4. Variance Request - Merrimack Eng., to groundwater OTHER BUSINESS: Town of North AndoverNORTH OFFICE OF 3a°,'"`� ",� COMMUNITY DEVELOPMENT AND SERVICES ° 30 School Street North Andover Massachusetts 01845 WILLIAM J. SCOTT Director August 12, 1997 Steve D' U rso 22 Lilly Pond Road W. Boxford, MA 01921 RE: 77 Boxford Street Dear Steve: This letter is to inform you that the proposed septic plan for 77 Boxford Street has been approved. If you have any questions, please do not hesitate to call the Board of Health office at the number below. Sincerely, Sandra Starr, 0 S. Health Administrator cc: Wm. Scott, Dir. CD&S Steve Borys File CONSERVATION 688-9530 HEALTH 68P-9540 PLANK—INC 588-9535 STEVEN J. D'URSO Environmental Designs 22 Lilly Pond Road W. Boxford, MA 01921 (508) 352-9872 TOf4�L2�%� \> > WE ARE SENDING YOUAttached ❑ Under separate cover via ❑ Shop drawings Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ [LIEUVIER OF VQLUSEDUML DATE DATE ATTENTIO RE JUL 3 1 19 f ❑ Samples the following items:" ❑ Specifications COPIES DATE NO. DESCRIPTION %7 THESE ARE TRANSMITTED as checked below: P- For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 REMARKS ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: (! nnnln.rrrs. .rw nn1 .e nn1eA LIn AI.. .. r.e 11.. ..- -• ......� NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT DATE -// FEE: PERMIT ## DATE RECEIVED l5_ 9-%/9 APPLICANT c�TEll�/U�4Ie�S MAP PARCEL ADDRESS LOT # STREET ## 77 ENG. TLS UE 'UeS dSTREET �i<,xo 5T ENGINEER'S ADD. D' -,-Z- Z/6LY �; O/V i' ) PLAN DATE CONDITIONS OF APPROVAL APPROVED REASONS FOR DISAPPROVAL: /SLG /�/pe;� �o -�6E TO L011, U 0 16 REV. DATE DISAPPROVED (/v, 14 6.0,2,; ) sc /-j 4--6 . VA- I&, l S -) Ir p/—, �,t°/�D�' i1/55//UG 62x,) TO O 5 Eb -� --FL Z a � UDa A'E i�EET; CN4 a, 14A Z&hz�AJ —770 -5,5 1.6 c c-_ Cl9LC Gnu 5/rte �iVOF sTP r& . TO O 5 Eb -� --FL Z a � UDa A'E i�EET; CN4 a, 14A Z&hz�AJ —770 -5,5 1.6 c c-_ BOARD OF HEALTH AGENDA LIBRARY CONFERENCE ROOM, TOWN HALL THURSDAY, AUGUST 7,1997 7:00 P.M. 1. Variance Request - New England Engineering, 1532 Salem Street - 310 CMR 15.212 depth to groundwater, 15.255(2) slope requirements and N.A. 14.01 distance between trenches 2. Variance Request - NE Engineering, 35 Evergreen Drive - 310 CMR 15.212 depth to groundwater and N.A. 14.01 Distance between trenches 3. Variance Request - NE Engineering, 29 Johnnycake St. - NA 14.01 distance between trenches and NA 5.02 Distance to wetlands (from 100' to 50') 4. Variance Request - Merrimack Eng., 66 Marion Drive 310 CMR 15.212 Depth to groundwater OTHER BUSINESS: a) Discussion of possible ssds procedure change b) Update on septic management program c) Update of Senior Aide worker r.7 I• l 05-- Em E PITS MIN 440 LEACHING MIN 1 (13'x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W)xD x ##) (G/ft2) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 60') MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W)xD x ##) (G/ft2) FIELDS MIN 440 GPD 900 ft2 BED GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED?- - 4" PEA STONE? C—' DIST LINE SLOPE .005? >31COVER-VENT " SCH 40_ MIN 12" COVER RATE ( 0 X L-0) X 6 = TOTAL L W LDG DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. inlet) HWL LWL CHECK VALVE OP. SWITCH ENUF STORAGE? TDH Copyright D 1996 by S.L. Starr GW' (Min. 1' below BLEEDER HOLE MANUAL WEIGHTED? J,�P)l fp-- PLAN REVIEW CHECKLIST kDDRESS 7z -ENGINEERX 1� 3ENERAL 3 COPIES v STAMP LOCUSy NORTH ARROW SCALE '-ONTOURS t/ PROFILE ✓/(Sc) SECTION -L,,--- BENCHMARK ~'SOIL & ?ERCS Qr--- ELEVATIONSY WETS. DISCLAIMER WELLS & WETS 4ATERSHED?A/0 DRIVEWAY!/ WATER LINE 04 FDN DRAIN M&P 3CH40,z TESTS CURRENT? C�� SOIL EVAL SEPTIC TANK II AIN 150OG .17 INVERT DROP v GARB. GRINDER) �-comps +200) 10' TO FDN I/ MANHOLE- ELEV ✓ GW L----## COMPS. ' GB D -BOX SIZE ## LINESA FIRST 2' LEVEL STATEMENT INLET 75 - OUTLET— = r ( 2" OR .17 FT) TEE REQ' D? 40 LEACHING MIN 440 GPD? RESERVE AREA 4' FROM PRIMARY? — 2% SLOPE !100' TO WETLANDS &-`� 100' TO WELLS v 4' TO S.H.GW L/ (5'>2M/IN) 20' TO FND & INTRCPTR DRAINS 400' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY MIN 12" COVER L/ FILL? ` (15') BREAKOUT MET? TRENCHES MIN 440 gpd W OR D (MIN 6') BE 10' MIN. SLOPE (min .005 or 6"/100') SIDEWALL DIST. 3X EFF. RESERVE BETWEEN TRENCHES? IN FILL? MUST 4" PEA STONE? BOT + SIDE (L x W x #) ( DxLx2x## ) Copyright 0 1996 by S.L. Starr VENT? (>3' COVER; LINES >501) X LDNG = TOT (G/ft2) G No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH AVVUration for Diiipvtial ftstrm Tonstrnrtion rrrmit Application is Dsxc4 made for a Permit t nstall ( ) or Repair/Replace (X) an Individd S al ewage Disposal System at: 37 00 xfDR-C� – r i� % OwneY Designer or Installer Type of Building Dwelling — No. of Bedrooms 114, 7 ,0 _ Lot No. /%'!7 Address Address Size Lot Sq. feet Expansion Attic /JiO Garbage Grinder Wo Other — Type of Building No. of persons Showers ( ) — Cafeteria ( ) Other fixtures Design Flow gallons per person per day. Calculated daily flow D gallons. Septic Tan Liquid capacity gallons Length _0Width Diameter Depth Disposal "�— No. / Width � Total Length � "Total leaching area e.9eO sq. ft. Seepage Pit No. Diameter Depth below inlet Total leaching area sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by S� �� 10? Date �Zg�9G Test Pit No. 1 _minutes per inch Depth of Test Pit f00 ` Dep to ground water Test Pit No. 2 _minutes per inch Depth of Test Pit'' Depth to ground water D Description of Soil Nature of Repairs or Alterations — Answer when applicable Ems" Date Last Inspected Agreement: — The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code. The undersigned fu ther agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board If Heal h. SignedX Date Application Approved By Application Disapproved for the following reasons: on for Permit No. Issued THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tntifiratr of Tnntphaurr Date Date Date THIS IS TO CERTIFY, That the On -Site Sewage Disposal System installed ( ) or Repaired/Replaced ( has been constructed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION AS DESIGNED. This Certificate expires on DATE Inspector No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH 43isposal `-piarm Tnnstrnrtinn Vrrmit Permission is hereby granted to to Construct ( ) or Repair/Replace ( ) an On -Site Sewage Disposal System located at Street as described on the application for Disposal System Construction Permit. The Applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. Board of Health DATE FORM 1255 (REV. 4/95) H&W HOBBS 8 WARREN TM PUBLISHERS - BOSTON THIS FORM APPROVED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION