292 Application & Permit 2006 No. (7(7//[
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THE COMMONWEALTH OF MASSACHUSETTS FeF '' rL'
G l r , F micrtmoinivi Iva Uti* t31BOARD ,OFHEALTH
APPLICATION
FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
,vnnI irnn fora Permitto Construct XRc'airL ) Upgrade I 1 Abandon I I - mplole System L Individual Components
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Type of Building:_ ALL-S r19GL a-L Lot Size Sq. feet
Dwelling—No. of Bedrooms S/h Garbage Grinder (4
Other—Type of Building Y,C. _ No. of persons N?/__ Showers ( ). Cafeteria ( )
Other fixtures A/A9--
Design Flow ( n r (uired) �6 0 ,,pd Calculated design floe 0 Bpd Design flow provided 64clopd
Plan: Date 3J`�77/C & Number of sheets ti Revision Date
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Description of Soil(s)_ WO'( Ldp}_fcn-# � ®��
Soil Evaluator Form No. A 4_/Z Name of Soil Evaluator AA, 44/2 —‘z Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 4/6w Coilflu%ZC'w /NGtJ-iO
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees to,lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
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Signed
Inspections
Date
FORM I - APPLICATION FOR D5CP
DEP APPROVED FORM /96
No
Description of Work:
THE COMVONWEALTH OF MASSACHUSETTS
! jq „? ' ifro A OARD OF HEALTH
CERTIFICAtE OF CO LIANCE
Individual Component(e) Complete System
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The undersigned hereby certify that the Sewage Disposal System:Constructed I4 Repaired( ).Upgraded( ).Abandoned( )
at
has been installed in accordance with yhe previsions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No %oAT dated_ / i Approved Design Floe. / 1 (gpd)
Installer /
Designer:41Clts(si' Inspector i {d/✓.
The issuance of this certificate shall not be construed as a guarantee thaf4he system will function as desi
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
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No. o'
THE COMMONWEALTH OF MASSACHUSETTS
v' /f�,,.�� � /I BOARD OF HEALTH
DISPOSAL SYSTEM,CONSTRUCTION PERMIT
Permission is hereby grganyed to Constyuct (I j Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at !</C C'i 1-L( v' .ct 1-_xv - - as described
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in the application for Disposal System Construction Permit No ✓i i j .dated `, 12.1 r
Provided: Construction shall he completed within three years of the date of this permit. All local conditions must he met.
yl?// utC 1-1<, Zric f /!;/” Board of Health � i0Za-s ;7//-/r
Date
FORM 2 - DSCP
FORM 1235 (REV 5/96)
DEP APPROVED FORM 5/96
HAW i) Noma n WARREN II"
PUBLISHERS - BOSTON