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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 44-D was-rat-ye-row Q.ohC-, L-tsllol.A k Su3At-4NG 2 Ss1N 44e WR=.st-iRtot,t ?o A Idreva /�ssExX25 N A?' 43 \L i�Ysm9 q e ES.S 5oeS lot !OS fC • if Ce�yIr N Sjai im - PS MA 4 rr Dcv' fl•rq�e Ndrn Qu e� 1y / `" r c COta4fi/S Addr.. d,... Id rPI i c 4 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