App-Permit-Compliance#� 1 9 -- CJGY1b
1, zd�
No. 6(4VC-0-60q3HE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD C, OF H E A LT H-,
��•! X CXt3 f\ OF T<Xr CCN400AlY�-
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair (Upgrade ( ) Abandon ( ) - �plete System ❑ Individual Components
4.5 LIQ
1� Location
11S- I'"
4 Map/Parcel #
L
Q e x (2010MA 101/
Installer's Name
14 r'%a.Sr_rru t j ForesAIL011L
Address
!T09- L4571- 0LS3
Telephone #
1 acro c rVy,y E S
Owner's Name
DDC r• Lr,,-)
Address
Tele hone #
F�Lal�c r ac . ENj_x Q0 IV fn E rmo,1
Designer's me
P D..�OX 81 os',Iv�pt�i�0i"'�
' 7v74 — 99. Address
Telephone #
Type of Building: QcS, 4=rA 11 o�_1
Dwelling — No. of Bedrooms 103
Other — Type of Building No. of persons
Other fixtures
Design Flow (min. required) X30 gpd Calculated design flow
Plan: Date 71- Z 9 - 1 9 Number of sheets '7 -
Description
Description of Soil(s)
Soil Evaluator Form
Name of Soil Evaluator
Lot Size Sq. feet
Garbage Grinder ( )
Showers ( ), Cafeteria
gpd Design flow provideda-gZ gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS M,001- Z- 5500 R<3_ 1 LI e.
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 2c2L-K, e -A e%,n- Date � 1 — n
11.j
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
-----------------------------------------------------------------
No. D 13 THE COMMONWEALTH OF MASSACHUSETt�,��FEE � X00
/7—BOARD OF HEALTH � 2 Co110
CERTIFICATE OF C NCE
Description of Work: [individual Component(s) mplete Syst
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (✓j Upgraded ( ), Abandoned ( )
by: .Q .Q E X C a U o. -i i o A. T
at S S k, anL>i Imo) alwoo/�1 `
has been installed in accordance with the pr visions of 310 CMR 100 (Title 5) and the approved design plus -built
plans relating to application No. � jf! dated rr 7r/ Approved Design Flow ✓J`al-g (gpd)
Installer n �,
Designer: S(Qt,� c,_ �Inspector Date if
The issuance of this certificate shall not be construed as a arantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
_ 3 ,2
No. lCgk C-j-1-0O5(3THE COMMONWEALTH OF MASSACHUSETTS FEE S QO
.t *` Ya,BOARD OF HEALTH#
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) an individual sewage
disposal system at y $ 5 KD__pr r L_NJ as described
in the application for Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. al conndiittiio t be et.
st
Date D 7 --/:2 Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM1255(REV 5/96)� jH&W HOBBS&WARR NTM PUBLISHERS - BOSTON