888 Septic Application 1997 7 H4 COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
191
ION FOR DISPOSAL SYSTEM CONSTRUCTIO
FEE /S6,00
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Permit to Construct (4 Repair ( ) Upgrade ( ) Abandon ) - L Complete Srslem _]Ind
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dual Components
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Dwelling—No. of Bedrooms 3
Other—Type of Building
Other fixtures
Design Flow(min. required) 330 apd Calculated design flow Lt4.0 2pd Design flow provided gpd
Plan: Date 5—W—O9 Number of sheets off— Revision Date
Title — ( �
Description of Soil(s) S/l. —('��S SAwo Cr E SAUD
Soil Evaluator Form No. Name of Soil Evaluator aC4e7 Date of Evaluation Ca-ti 11
DESCRIPTION OF REPAIRS OR ALTERATIONS 01Af
No.of persons
Lot Size Sq. feet
Garbage Grinder ( )
Showers h----(Cafeteria ( )
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TIRE S and further agrees not to place the system in operation unfil a Certificate of Compliance has bee ryissued py the Board of Health.
Signed
Inspections
Date
7
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
3