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No. 000c—o-403 THE COMMONWEALTH OF MASSACHUSETTS FEE arm
/7—/�, BOARD OF HEALTH CkftK.,
-0 F Y144At0Ll
L� CA I - FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construc�epair ( ) Upgrade ( ) Abandon ( ) - XComplete System ❑ Individual Components
Location
Map/Parcel #
Lot #
O Ail e- a
Installer's Name
Address
Owner's Name
S-11 Ao4e
Address
Te ephoae*#
l�es�ge, r's Iame`rill dam= 1,4-
,TeleTelephone
phone #
Type of Building: S7i e FAamI Lot Size 140 1 Sq. feet
Dwelling — No. of Bedrooms Garbage Grinder (A4 -
Other — Type of Building ens Showers (:3), Cafeteria ( )
Other fixtures
Design Flow (min. required) 60 gpd Calculated design flow gpd Design flow provided 4L—() gpd
Plan: Date 44, 1 ig - t' �iilibeer off sheet Revision Date
Title j OP4L��j^ ttA'
Description of Soil(s) LOCI' 76
Soil Evaluator Form No. Namedf Soil Evaluatore'er Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERAT NS i►^� I ���� �� {''
%ll, S A-9 I
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 I e system in operation until a Certificate of Compliance has beenissuedby the Board of Health.
Signed "� Date 2�
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. �oN DC.-l�'tiU3l THE COMMONWEALTH1 8 �MA S�A�CHU S ® - _ O, Ob
Y4,)iiAyLM± BOARD OF HEALTH)IF /I 411'. 4-8-7q5
CERTIFICATE OF COMPLIANCE'' (_
Description of Work: ❑ Individual Component(s) �'mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed; Repaired ( ), Upgraded ( ), Abandoned ( )
at 22.1 ST-,
has been installed in accordance with t1je ntrovisions of 310 CM 15.00 (Title 5) and the approved desig s/as-built
plans relating to application No. 7 ` dated Approved Design Flow (gpd)
Installer SGO �j
Designer: h?o&C-ILT M. PC-Y4r-V Inspector Date Ca
The issuance of this certificate shall not be construed as a grantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
TO'ete 1 EX CAVA7701-%
No. bobyc"(7-gO-5/THE COMMONWEALTH OF MASSACHUSETTS FEE
//-� VA -2M00131- BOARD OF HEALTH C"8 -7Y,5 --
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct
Repair ( } Upgrade ( ) Abandon ( ) an individual sewage
disposal system at 2.2( CO ZZE- Z SEE77 as described
in the application for Disposal System Construction Permit No. , dated c;,,12-/
�—/
Provided: Construction shall be completed within.tYwe-*rsao the date of this pest- t.(M1local conditions must be met.
% /�
Date � Board of Healt r
FORM 2 - DSCP DE;P APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS - BOSTON