140 Septic Application & Permit 2010 No. h40 -21 THE COMMONWEALTH OF MASSACHUSETTS v
0 BOARD OF1 HEALTH
rt 4y OF NOr
APPLICATION FOR /DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( 1 Abandon ( ) - Complete System ❑Individual Components
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Address
Address
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Telephone:
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Type of Building:
Dwelling—No.of Redroo
Other—Type of Building
Other fixtures
Lot Size Sq. feet
//Garbage Grinder (/<O
No.of persons LP Showers ( ), Cafeteria ( )
Design Flow(min. required) 330 gpd Calculated design flow epd Design flav prt}etded 3g9gpd
Plan: Date /O -/2 -/D Number of sheets //.247111/49" Revision Date I) - ub-IC/
Title S---"se r..9 a e -Di pOSo-Q S3.1"!-Qv-- -'(-�e'pelir— - / n k - ?a' lz9
Description of Soil(s) C — y+__ _ _ iy�ou��rtiei et7N,e—�
Soil Evaluator Form No. Name Soil Evaluator .e-S" i Q. ,(rag—Date of haluation /a -L2-10
DESCRIPTION OF REPAIRS OR ALTERATIONS
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the syr)ehp in operation until a Certificate of Compliance has been issued by the Board of Health.
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FORM I - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
No o/0 a'
Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired( ).Upgraded( ).Abandoned( )
by:
at
has been installed in accordance with the provisions of 310 CMR 13.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated . Approved Design Flow (gpd)
Installer
Designer: Inspector Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. ri20/0 7
THE COMMONWEALTH OF MASSACHUSETTS
, ,4
/Jor4 n BOARD OF HEALTH
DISPOSAL SYSTEM CONS UCTION PERMIT
Permission is hereby granted to Construct ( NhRepair ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at AO Co/VS fiLta.Gn/ '2cY as described
in the application for Disposal System Construction Permit No. a0/0 _2 7 dated F7 a0
Provided: Construction shall he completed within three years of the date of this permit. All local conditions
Date //, 2 V/0 Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
So
FORM 1255 f REV 5/961
rHSWM Hoees b WARREN r'
PUBLISHERS-BOSTON