246 Application & Permit 1999 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Cc%: e> OF ^ i l kt>r , ; tc tiC
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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T■pc of Building. J(„L.O lO l)
Dwelling—No. of Bedrooms'
Other—.type of Ruildim,
Other fixtures
Design Flow (nun.required)
Plan: Date / / l
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Description of Soil(s(r l /
Soil Evaluator Form No
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No.of persons
Lot Site Sq. feet
Garbage Grinder (V)
i / Showers ( ). Cafeteria (
gpc Calculated desicn flow "pd Design flow pro)ided'`/4 gp(
Number of Meets % Re.ision Date
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NameofSoil Elulumor/) L I„EL Date of FA al nation 3
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DESCRIPTION OF REPAIRS ORAITERATIONS �. L 'r X ; 1 I =' i-,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agree p not lo placA the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Th
.0 Signed
Inspections
Date
to/ y/97
FORM 1 - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
No i 1. THE COMMONWEALTH OF MASSACHUSETTS F EE /--
/ -»f t w't Md. BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE A% '�
Description of Work: i Individual Component(s) ❑Complete System i_1': -,1 u 4, .
The undersii ned hereby cenifk that the Sewage Disposal System:Constructed t 1. Repaired t ).l:pgraded(4').Abandoned( )_
tl
at >li
has been Installed in accordance with the a/visions Of 310 C.WR I 9f) (Title 5) and the approved design plans/is-built
plans relating tvxpplication No. dated - �' % l Approved Design 1 low ., (gpd)
Installer - ^,.- - t A
/
Designer t - Inspector _, �✓L/ - -
r -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
Ilk ) >!f/�5
THE COMMONWEALTH OF MASSACHUSETTS FEE S()
1/« . - BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( U>j grade ( ) Abandon ( ) an individual sewage
disposal system at as described
in the application for Disposal System Construction Permit No. .dated
Provided: Construction shall be completed within three years of the date of this permit, All local conditions must be met,
/
Date Board of Health - _
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 1 REV 5/961
KR IA, > HOBBS&WARREN r"
PUBLISHERS - BOSTON