1526 Application & Permit 2006 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF� HEALTH
C l T / OF NOIM ts-Mp I- V%:
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Frr/SU. ( a
CAw( qa1•
pplieution for a Pcrnin to Construct (KRepair t ) Upgrade ( ) Abandon ( ) - Complete System n Individual Components
536 WEST*AM(SION P-ObgP
PRU(, 4 MA9cMEUF MtGyrc,, orJ
4404.rEc .L3
1R 4La)lDwVE-�cxtsuct
(413) cell-- 3.4` a_
TvlapLOOa t
rtnrv,.zis
4a=
It E. ✓NlrcatNNts
10 1MDw-TAGU6 0.cap,, - a
(4t-, 521 - 57-9
re of Building: 6&N61$ F/t '.LY MOVVta- Lot Size 101,3% t Sq.feet
oiling—No.of Bedrooms 4- Garbage Grinder (✓)
ter—Type of Building No.of persons & Showers (kl. r'^f lore f
ter fixtures
sign Flow(min. required)4-4-0 gpd Calculated design flow (.4o0 gpd Design flow provided115157pd
n: Date'DEC. L$? 20o6
U
c --. :
Number of sheets o1 Revision Date
— -o4M SftbJD set-ninon puon of Soil(s) Sq MDR l.0et — # p SerND
I Evaluator Form No. Name of Soil Evaluatorflaray 80✓ -t Late of Evaluation Oa. C
SCRIPIION OF REPAIRS OR ALTERATIONS�A�A - 11i- $ IS IJEu) Cclk),gYlW(1to I
the undersigned agrees -II e abo escribed Individual Sewage Disposal System in accordance with the provisions of
E 5 and further agree '•r pl•/+4,- Aligner,the sys in until a Certificate of Compliance has i ss by the Board of Health.
IRA /AS Date
pections
RM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
0U[- 31/4- THE COMMONWEALTH OF MASSACHUSETTS
U0iaT r ,w ci i BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
criplion of Work: ❑ Individual Component(s) t[-'omplete System
undersigned hereby certify that the Sewage Disposal System:Constructed(;...4epaired( ),Upgraded( ),Abandoned( )
. e , .- , , 33 is
been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/`as-built
is relating to application No.,;'-i'..-'- dated jA -,!- w^ . Approved Design Flow (DV: (gpd)
alley I W .1-C'�^ - -
Inspector iii Vt. X7�.`-��i Dale f ( .�
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
RM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
i
THE COMMONWEALTH OF MASSACHUSETTS
Hor.,MAYsirQN BOARD OF HEALTH
(saefk..;,:fi,: \
is 1
Fee 6, OO
i P4.c4' -/.._i'
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( V) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage
sstsal system at / *
jr,described
he application for Disposal System Construction Permit No. I( (1 C..- ? i .dated / 7/ / �G6in
vided: Construction shall he completed within three years of the date of this permitt,411 local copditions must he met
Board of Health /�ij2/-1 r-7 f7/f' ✓-,r.!:s.)
RM 2 - DSCP DEP APPROVED FORM 5/96
IM 1255 'REV 5/96F
FHA Hoses a WARREN
PUBLISHERS-BOSTON