17 Application & Permit 2012 a!
FEE
COMMONWEALTH OF MASSACHUSETTS
' Board of Health, ^/G/2%/{Amp/4cMA
"LICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
mit to Construct( ) Repair( Upgrade Abandon( ) - Complete System ❑Individual Components
LYcE
-cell(/7 040 Ate
o/2rNfi'+'/ 9o&i AO/
'shame J W LO] ry %LC
Stye " Si a 61 40P
2Y
ine
uilding S/PFR/77/4/i/10/14,
gearoo v'TM MS
y of Bedrooms / /9'»'L
ype of Building
POLL- w /tq
:ores G I/9r Design flow provided SO gpd•
tier Y/ gp� Calculated design flow
to (min."VG Revision Date ---
te ✓ t�L 9 0 ZNumberofsheets it Q j F.rre
1
Owner'sNamea/it tiPecole/
Address/7OLa Arrest
Designer's Name 1JfttjJffl4 ,^
Address /8 /XAorR6 “4/441-77
s '
OsI L
Lot Size �ri5
sq.fad
Garbage grinder�C
No.of persons Showers(/).Cafeteria We
Ion of Soil(s)
// Name of Soil Evalua r Lf%`T'SLLEd� Date of Evaluation
uamr Form No. ^� jd/I,8 ‘5.• o7; 5//
PTION OF REPAIRS OR T�FRATIONS
a gree ed agrees to install thetem in operation until Individual eroicatte of Compliance bas been issued by the Board of Health.
5 and
agrees�no mpce e. operation gyl.7/L�.
Date
Lions
COMMONWEALTH OF MASSACHUSETTS
Board of Health, I / /,i , .2 lo frit MA.
CERTIFICATE OF COMPLIANCE
on of Work: ❑Individual Component(s) ❑Complete System
ersigned hereby certify that the Sewage Disposal System; Constructed ( ).Repaired( ).Upgraded .Abandoned ( )
/< c , ..e
instilled in accordarfce with the pmsdsions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
on No. "/—/ i dated c - ,-� Approved Design Flow / /, (gpd)
(/../. . IP /` 'ire q -
�. — %l�/ 1 e t - Date:
ante of this permit shall not be construed as a guarantee that the system will function as designed.
FEE r/_
FE
r, _>G
COMMONWEALTH OF MASSACHUSETTS
Board of Health, / MA.
n
DISPOSAL SYSTEM CONSTRUCTION PERMIT
sion is hereby granted to; Construct( ) Repair( ) Upgrade( /) Abandon( ) an individual sewage disposal system
/\\ as described in the application for
al System Construction Permit No. ( / ) �;1 dated c/
ed: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Rev.5196 A M Su010 Co.CIAMAREA,MA Date
Board of Health