440 Application & Permit 2001 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1-CY OF
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI
Application lera Permit In Construct I 1 Repair I/Upgrade 1 1 Abandon 1 ) - ❑Complete System ❑Ind
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Type of Building: St 041,9- PIkM 11.-`1
Dwelling—No.of Bedrooms rj
Other—Type of Building
Lot Size 12 Sq.-feet AC.
Garbage Grinder ( )
Showers ( ), Cafeteria ( )
No.of persons
Other fixtures
Design Flow (min. required) 550 gpd Calculated design flow SZE !,pd Design flow provided eSet gpd
Plan: Date i-23-o 1 Number of sheets 4 Revision Date
Title L a� e...t�.Tf(te_
Description of Soil(s)
jl Name of Soil Evaluator P L Fla QQ68Av(1 Date of Evaluation !a-cs--(0 l
k
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS t
e-ACM- 'F1 Iao - CS COS W rill S-Ist 1/44
6
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with she provisions of
TIRE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
FORM I - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
Jo C/ 7-/ / THE COMMON E,ALTH OF MASSACHUSETTS
l ,v7.4,,„(..., // BOARD OF HEALTH
CERTI CATE OF COMPLIANCE
)eseription of Work: ❑ Individual Component(s) If�eplete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired({Upgraded( ).Abandoned( )
n
a 07/ /J -1 af eLT32 44:`++ /&
tas been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
Hans relating to application No. dated Approved Design Flow (god)
uO 3-Ul e" ri/e- Date 72/2/3-../
3esigner: s�-.r-/ r^" ,%i -� inspector
it
The issuance of this certificate shall not be construed as a guarantee that the system will function as desgned.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
FEE J:/1 .t
THE COMMONWEALTH OF MASSACHUSETTS
00i ))//19 /4 BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) epair ( J/Upgfadt,�;` ) Abandon ( ) an individual sewage
40 Pie5.11 flm i G'/,/ as described
disposal system at w/
in the application for Disposal System Construction Permit n. (3,A- i( ,dated 7/t;`/r
Provided: Cpnstruf{ion shall be completed within three years of the date of this permit A)lecal acrid. >v y•met.
Date x:/%71 / Board of Health 'G
FORM 2 -DSC/ DEP APPROVED FORM 5/96
FORM 1255 (REV 5/961 11&W1) HOBBS A WARREN'°
PUBLISHERS- BOSTON