Lot 5 Septic Application & Permit • No. /2
THE COMMONWEALTH OF MASSACHUSETTS Prr 7-C
BOARD OF HEALTH
0(A k ) OF 4 Uo r+ c to t&)
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
‘ppllcirmi ibr a r,rmn m t bnarrict Repair 1 t per:ul_
/Crf uc* BO`d_
-coiresiiro,5 (auk
A P:mdon I X( emplar S■• ean _Indi,!Judi('onipaeni.
Je/ Ezr fL en('
/3ox31 A)„r+l ert7cr.), . . I
55y - 9G 9_�(.) crQLAD
E/V Ji roraQ/.JLc _t/ e_ /d Spru, c-ems
Pci oxS1g rPe „C. fill r} o/0,3
Type of Building-.IA 'c ��.0 nxi 1,3
Dwelling—No.of Bedroc is ri �J
Other-T pe of Building
Other fixtures
Design Flute(min. require I) CZ epd Calculated design flow gpd Design flow p rocidcA 4o_gpd
Plan: Date )c- 1 3' 98 Number f sheets / Recision Date
Title Sew44F his oSO! S. Sten, - -.7ulcheC —
Description of Soil(s) SG-r_ r i -11 4 I i2..." 170 r- SA
I iot Size Sq.feet
(^� Garbage Grinder f
No. of person Showers ( I. Cafeteria
Soil Evaluator Form No. Name of Soil •v'tluvor Th .CCU}5 AJQ Date of Evaluation G %9
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 further agrees not to pl•ce the system in operation until a Certificate of Compliance has been issued by the Board of Health.
e` I� �
Date IZ\��I�K
Signed
Inspection
J
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
a
No. ti
THE COMMONWEALTH OF MASSACHUSETTS
et-Inl7Lr A, BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: [] Individual Componengs)
The undersigned hereby ccrtil that the S aze Disposal System
S.
by: / �' AOL.! CPI �127�#S-/ AV1C lI /.(
r
at /- u. .r I NC c /<r-� JW �., ,
has been installed in accordance ys ith the provisions of 310 CMR 1 5.011 (Title 5) and the appror d design plan
plans relating to application No. y- 'J _ dated 4--"' / °�'j Approved Design Flo y W
JCmnplete System
Irncted( . Repaired t ).t
p
I
ed( ).Abandoned( )
is-h uilt
(upd)
Installer - - - - e ,� /
Designer /C. '^ Inspector �t�4- / '
--- Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No
THE COMMONWEALTH OF MASSACHUSETTS
Q a� 1 ' / 'I_:d_BOARD OF HEALTH
DISPOSAL SYSTtM CONSTRUCTION PERMIT
/
Permission is hereby _granted Vo Construct 1,..A',/Repair ( ) 1
L p rade
disposal system at L✓:r 7/!E.
_
in the application for Disposal System Construction Permit No. y
Abandon
an individual scavage
as described
dated /7`�'c
Provided: C1812 2611 shall be compled within three years of the date of this permit AU lidtal conditions tile met.
Date / /7/ 2 Hoard of Health Y/f< dJ ul ___
A
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 1REV 5/961 IMti I Hoses d WARREN ° PUBLISHERS BOSTON