79 Septic Permit 2004 No. 205 V- oy THE COMMONWEALTH OF MASSACHUSETTS FEE Saab
BOARD OF HEALTH Glee (<
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon (V- 0 Complete System O Individual Components
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Type of Building: -C/N G c C A.79,,/_. Lot Size %/h' Sq.feet
Dwelling—No.of Bedrooms 3 Garbage Grinder ( )
Other—Type of Building No.of persons 3 Showers (/), Cafeteria ( )
Other fixtures
Design Flow( required) opd Calculated design flow gpd Design flow provided gpd
Plan: Date fig) I/ %OQ 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 ALTERATIONS 7--/e>9 f&,072-'&
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The undersigned agrees to install the above described Individual Sewage Dispose System in accordance with the provisions of
TITIE 5 and further rees not to place the system in operation until a Certificate . •nce has been issued by the Board of Health.
Signed
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Inspecfio -
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
JAMES BRAZEAU
P.O.80X367 PH.41346842W
GOSHEN,MA 01032-034v
For
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