132 Septic Application & Permit 1999 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
'tnrfo lc nitto(b or t 1 1 I2grolr 1' 1 I'ppcWe 1 ,ObaiKlon 1 ) IidvJu9 ()rilponero,
Type of Building:
Dwelling—No of Bedrooms
Other—Type of Building
Other fixtures
Design Flow(min. required)
Plan; Date
Title
Description of Soil(s)
Soil Evaluator Form No.
No, of person,
lot Size Sq.feet
Garbage Grinder (
Showers ( ). Cafeteria
Calculated design flow
.ypd Design flow presided—1 gpd
Number of sheets r Revision Date
Name of Soil Evaluator_ : Date of Evaluation
DESCRIPTION OF REPAIRS OR AI:IERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fu er agrees not to plat the system ip operation until a Certificate of Compliance has been issued by the Board of Health.
aSigncd ia%ke-ec/ I l' Date X* `/"--
Inspections
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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Type of Building:
Dwelling—No of Bedrooms
Other—Type of Building
Other fixtures
Design Flow(min. required)
Plan; Date
Title
Description of Soil(s)
Soil Evaluator Form No.
No, of person,
lot Size Sq.feet
Garbage Grinder (
Showers ( ). Cafeteria
Calculated design flow
.ypd Design flow presided—1 gpd
Number of sheets r Revision Date
Name of Soil Evaluator_ : Date of Evaluation
DESCRIPTION OF REPAIRS OR AI:IERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fu er agrees not to plat the system ip operation until a Certificate of Compliance has been issued by the Board of Health.
aSigncd ia%ke-ec/ I l' Date X* `/"--
Inspections
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
THE COMMONWEALTH/1>F MASSACHUSETTS
4; BOARD OF HEALTH
,c1
CERTIFICATE OF COMPLIANCE
Description of Work: Vf Individual Component(s) E Complete System
The undersigned he r ry cceertify that the Sc"age Disposal S■slen onstructed I 1. Repaired( Abandoned ( )
Fr
at
has been installed in accordance alit t the provisions of 310 CMR 15.00 (Title 5) and the approved designplpn}'as-built
plans relating to application No. dated Approved Design Flow 1 (gpd)
Designer: 'tq }' '' / Inspector /f5rr ,_3,_Dule
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.
THE COMMONWEALTH OF MASSACHUSETTS
' BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herehv granted IQ Construct ( ;;) Rgpair ( fi Upgrade ( ) Abandon ( ) an individual sewage
as described
disposal system at - 1 :' '`??// /'-r
in the application for Disposal System Construction Permit No. 7 1f>f". /1 .dated
Provided: Construction shall be completed within three years of the date of this p
Date
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 1 REV 5/96 °H/..W. MORES fl WARREN it
Board of Health
nit: AILlocal conditions.must he met.
PUBLISHERS - BOSTON