330 Septic Application 2008 A
;
Commonwealth of
Massachusetts
City/Town of
Application for Disposal
System Construction Permit
Form 1A
ZeaB—o /
Jer
$ S d. Od ()
Ci-d# V 3y
DEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Important:When lication is hereby made for a permit to:❑ Construct a new on-site sewage disposal system
filling out forms on ❑ Repair or replace an existing on-site sewage disposal system
the computer,use
only the tab key to
move your cursor-
do not use the Location of Facility:
return key.
*Repair or replace an existing system component
330 Cnl s /'f-4bt,s
Address or Lot# �
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City/Town
2, Owner Information
kJ AcCan%
Sta (
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7in Cnde
Name
>, �I 146
7—a /'- -f/&
Address(if different fro above)
�t u.
City/Town tale
laa7- 06if
3. Installer Information
• frat) s,fe coos r
06357
7in code
Telephone Number
Name �// ,n
n7 move- N/✓.
Address
• Hailc'j
City/Town
Name of Company
4. Designer Information
S 4• Ola
State 3l
m Cnde
• 7w7y� Syr-t--sJf&
Telep ne Nu ber
Name Name of Company
t5formta.doc-06/03 Application for Disposal System Construction Permit -
Page 1 of 3
Commonwealth of
Massachusetts
City/Town of
Application for Disposal
System Construction Permit
Form 1A
20i - 0 /
Number
$ S,06
Fee
33D ( vG*emuQefr 1112 —
Address
City/Town ,
State
oe0 a
nn cnda
Telephone Number
A. Facility Information (continued)
Type of Building:
Dwelling ❑ Garbage Grinder(check if present)
Other: Type of Building
Numhar nt PArsnns Served
❑ Showers ❑ Cafeteria ❑ Other fixtures
Number of showers
Specify other fixtures:
Design Flow:
Calculated Daily Flow:
Plan:
N/4-
Number of Sheets
Title of Plan
Description of Soil:
Gallons per Day /
Gallons
�
Date of Original '/
Raviaippn�e/v
�� Qei!%L 11w
t5formla.do •06/03 Application for Disposal System Construction Permit •
Page 2 of 3
r
Commonwealth of
Massachusetts
City/Town of
Application for Disposal
System Construction Permit
tiff
;et B !
Number
Nat.ure of Repairs or Alterations Of applicable):
A, vee. frier2
Date last inspected: (TS.' C �
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and
•
Date
177q4 7
Signature
Applicatio. Approve. lust
ifid
Name
Application Disapproved for the following reasons:
!/ii/eP
Date
nat>1/447
t5form1a.doc 06/03 Application for Disposal System Construction Permit •
Page 3 of 3
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key
isC
Commonwealth of Massachusetts
City/Town of
Disposal System Construction Permit
Form 2A
Number
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
Permission is hereby granted to:
Pc, Nam Company
t5for2a don.00/03
State
to perform the following work on an on-site sewage disposal system:
❑ Construction
❑ Repair or replacement /') -� /(_
Repair or replacement of system components —,003. "/�//XJ
c A-4 at
Facility Address N N
City/Town cc /r
Owner (^
o/alit)
Zip Code
State. Zip Code
ne
Telephone Number
The work to be performed is further described in the Application for Disposal System Construction
Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions
or special c nditions: )
All co struction ust be cpleted within three years of he da below.
l 5-4S-
Date
Disposal System Construction Permit•Page 1 of 1
Important:When
Ming out rams
on the computer,
use only the tab
key to move your
cursor-do not
use the return
key.
Commonwealth of Massachusetts
City/Town of
Certificate of Compliance
Form 3
DEP has provided this form for use by local Boards of Health. Other forms may be used but the
information must be substantially the same as that provided here. Before using this form,check with
the local Board of Health to determine the form they use.
This is to Certify that the following work on an On-Site Sewage Disposal System
❑ Construction of a new system
❑�,/Repair or replacement of an existing system
� ' Repair or replacement of an existing system component 9 .60.74
Has been done in accordance with Title 5 and the Disposal yst m Construction Permit(DSCP):
DSCP Numlyp /n^ DSC Oat
rK`
Facility Owner
Street ddteas or Lot
Designer Information:
Name
K
Signature
Installer Information: �(
rl L
Nam
State Zip Code
rrt
Name of Company
Date
Name of Company
A
Signature Data
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that t system will function as
designed
Approvi TA 9odty
Signature Date
S or
t5form3.doc•06/03 Certificate of Compliance•Page 1 of 1