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No. 8b"C-1 /-'3v" THE COMMONWEALTH OF MASSACHUSETTS FEE 4
BOARDF HEALTH ,�
0 OF � ��A�`C�
APPLICATION FOR DISPOSA SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade (�bandon ( ) El Complete System -- tj t Nidual Components
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y7// Location /
Map/Parcel #
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7�'� -17 y In [alley's Names
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Telephone #k
elephone #
Designer's Name
Address
Telephone #
Type of Building: ° Lot Size V' /°�'F,:f�ef
Dwelling — No. of Bedrooms Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow (min. re wired) gpd Calculated design flow gpd Design flow provide& pd
Plan: Date Iz� I d C Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONSV
( io & Lo Y,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and furtkwglatgrees not to place the systelp in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 1Z/'2(0
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. �JpIa�C-1���38� T7-1
COMMONWEALTH OF MASSACHUSET�e9-, �JIFEE D�
Ad- ®BOARD OF HEALTH (/ (
C RTIFICATE OF COMPLIANCE- ' of
Description of Work: EJ_Wividual Component(s). ❑ Complete System Stn �leiQ
The undersigned hereby certify that the Sewage Disposalf4Stem; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: MiLD C X C 10
at 2- C -CAP i itj 2D -(I q-)
has been installed in accordance w the p ovisions of"
plans rela ' to application No. B 'dated.
Installer obpz I U, -
Designer. D � L . A� V I U' I -f (C Ct-( Inspecl
The issuance of this certificate shall not be construed as
.00 (Title 5) and the approved design plans/as-built
Approved Design Flow(gpd
/��_ lam/
or
Date
that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. 004D(-Q-1380rHE C MMONWEALTH OF MASSACHUSETTS FEE UfZ, S--tr j. 0U
BOARD OF HEALTH Oa7
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at f- r } , " n as described
( _ de
in the application for Disposal System Construction Permit No. ,� dated �Q
Provided: Construction shall be completed withiqt4A�llhe date of this permit1 cal ccoofnndiition be met.
Date Board of Health (--�1
;A'
FORM 2 - DSCP DEP APPROVED FORM 5/96 i
FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON