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No. / THE COMMONWEALTH OF MASSACHUSETTS FEE
j� BOARD F HEALTH
OF
CATIO FOR DISPOS L SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( Abandon ( ) - []Complete System Individual Components
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M,a`p-//Parcel(#
Lot 4
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per— Installer's Name
(� d
Telephone #
Type of Building:WSJ
Dwelling — No. of Bedrooms
Other — Type of Building
Other fixtures
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Owner's Name
of persons
Address
Telephone #
Designer's Name
Address
Telephone #
Lot Size Sq. feet
Garbage Grinder ( )
Showers ( ), Cafeteria
Design Flow (min. re uired) '9 q6 gpd Calculated design flow 1 gpd Design flow provided Z77 gpd
Plan: Date %i� I i Number of sheets Revision Date
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and furt Tees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date IZ� 11
Inspections —2
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No {1
THEf OMMONWEALTH OF MASSACHUSETTS FE S?
BOARD OF HEAL
T-`
C RTIFICATE OF COMPLIANCE d'k, p - /6 ' f8
Description of Work: Elindividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded( Abandoned( )
by: - °6 (( r_jVaf(& n
at 1-7 LJ Q D w i cr k.l ae N AJ ,yCt e 6Y) OLA r)
has been installed in accordance with t e provisions of 310 C R 15.00 (Title 5) and the approved des' a /as -built
plans relatin _ o application No. 17 I161 dated �27 2 6 r 7 Approved Design Flov �_(gpd)
Installer L� �
Designer: _DoL. o 11 t f_: KL/T Inspector ZM CW Date 1/'",,9 /t�5
The issuance of this certificate shall not be construed as guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
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No. 604 DC4_7-13-7�THE COMMONWEALTH OF MASSACHUSETTS FEE
J �—Ij2 e ([] { BOARD OF HEALTH &-71 0
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted -to Construct ( ) Repair ( ) Upgrade( Abandon ( ) an individual sewage
disposal system at HGLL,DLDl LD 171, f f1 , LA, as described
/
in the application for Disposal System Construction Permit No. dated 12 '-� V r/
Provided: Construction shall be completed within4h*4e(fs4of le date of this permit. oca))l conditionus
Date 12 J t be met.
Board of Health C/C�/G��
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS - KSTON