511 Application & Permit 1999 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7-Cc-CA ; OF k r)r-I-ho m 000
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
-l un loci l II m(,ni<Irua tX) R:pah I uu IL I t ..AI Indult I I ,y, ompkiL „R. L IntILiJi, l f ornporkrii.
Su' I ue Ste
Tiuwi 1 c1;
3I/z.591u f 5ttrarl Dorthain/dm
HAT�_
eNUiFOl( )l-4 P,v , riedSyrvlrl�
3s II/Uorflic t x
ft pc of Handing Bedro i2 ila,"nthAli�
Tcolline—No.ofBedn u
Aker Tope of Buildine
>thet routes
>esign Flu" Orin lett»nreed)Li 95- epd Calculated design Ilou gpd Design llosc prodded:. epd
,'Ian: Date.5-no-Y9 Number of.heels / Res Hon Date 6-0–'l 'I
ritlr- Sit Qye Di SVcSc ) SjSt-em -Z0 Wet) tCK
Description of Snips) 'CC rn 4 .SQ-n d - SR Q Se I / ✓2 2 %�S
c II Evaluator Form No. Name of Soil ['valuator .rV)L(2U�i 5 A 4 Date of Fvnluation 7/.9// r%,Q
DESCRIVIION OF REPAIRS OR ALI LRATIONS
I u1 Sim Sq. feet
/ Garbage Grinder ( )
No. of persons b Shooers ( ). CuIeIeriu )
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
'ITIF 5 and further agrees�nottoto place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Merril Data gi�ff
Inspections v / 111
rORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No.
Description of Work:
THEICO�MrytONWE4ALTH OF MASSACHUSETTS
�✓( R+
Kr.iiu,4.i,.e.,a.EOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Individual Component(s) j Complete Sc stem
The and raig here h certify that Sewage Disposal Scst em:Cons!m etedI )-Repaired( I.Upgraded( Abandoned( 1
b> r I,t_s�
, 1 at 14-+ t w.. - jz - l l ∎ta ,c i ' r;
has been installed in accordance with the4wyeSsions o}`310 (A1121_5 011 (Tile 5) and the Ippriced design plarnlas-built
plans relating to apphcatiodN� I, �y dated k.- /CI-41f ApprocedDesign Plow («pd)
Installer
Designer: fl Y }..Y�' r L:< _ Inspector /.- _�a-, <=]/ rc iY-
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. /(/—i7
THE COMMONWEALTH OF MASSACHUSETTS
gi/rCLt•n ?w-BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( pair,�" ) Up ade ( ) Abend( 1 ( to incl.ividual sewage
disposal system at �of / S /Ve F'y' F� • an WC"- v +�G as described
/
in the application for Disposal System Construction Permit No. /47.- '%`J . dated -
Provided: Con fu permit.shall he completed within three years of the date of this perm I k H conditi s Irwsr]tc met
Date Lit-( /[/ /7 Board of Health -- tyteg< -7 ,
FORM 2 - DSCP DEP APPROVED FORM 5/96
=ORM 1255 !REV 5/961 I ICdy ) Hoses&WEEPEN!"
PUBLISHERS - BOSTON