860 Septic Application Permit & Compliance 2002 No.
THE COMMONWEALTH OF MASSACHUSETTS FEE / S�
/ BOARD OF HEALTH HEALTH
`I-ty OF Nor#k4Vnp tit
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct (4 Repair ( ) Upgrade ( ) Abandon ( ) - • mplete System ❑Individual Components
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Type of Building: cirx51e c ty bWe 1 '145
Dwelling—No.of Bedrooms 4
Other—Type of Building No. of persons
Lot Size 2,3t Acts Sq.feet
Garbage Grinder (6.<
Showers ( ). Cafeteria ( )
Other fixtures
Design Flow(min. re uired) 660 and Calculated design flow 660 gpd Design flow provided 668 epd
Plan: Date /0/to/aZ Number of sheets ( Revision Date
Title S.Dnye_ bi'spos41 Sy.rlw-.,
Description of Soil(s) See 50;I EVAI. "grnA I I
Soil Evaluator Form No. Name of Soil Evaluator l"L Soleop Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS P McErl4in
The undersigned agrees to install bove described I I idual Sewage Disposal System in accordance with the provisions of
TRIF S and .i agrees not to pla ystem in apere I a Certificate of Compliance has ben issued by the lii...
p, Date OFD"
Signed y
777 cm
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
Description of Work:
THE(COMMONWEALTH OF MASSACHUSETTS
/VO1? katHOTHs BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) ,Complete System
FEE
The undersigned hereby certify"at the Sewage Disposal System:Const ucted( ). Repaired( ).Upgraded( ).Abandoned 1
at !L:(1 r,/, ^,_IC . i l
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. `.try 2'- dated //� - /.45-r- =- . Approved Design Flow G 6 6 (gpd)
Installer %� yr-zt-'i !-� /h-
Designer: //la/L !` rs"9t.I-i Inspector
�i-/ *-/ , ,. /,:_ 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
-r
No. - -- THE COMMONWEALTH OF MASSACHUSETTS Fan
Nor 4 {tvntp J h BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is here anted to Construct (vr) Repair ( '/ Upgrade-( ) Abandon ( ) an indi
r ,a
disposal system at / r./.)1 %� � -
in the application for Disposal System Construction Permit No. - dated `
Provided: Construction shall be completed within three years of the date of this permit.Alldocal conditions mustbe met.
/
Date I - r Board of Health -
dual sewage
as described
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/961
' HAW) HOBBS&WARREN
PUBLISHERS- BOSTON