423 Application & Permit 2003 THE COMMONWEALTH OF.MASSACHUSETTS
BOARD OF HEALTH
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
ecation fora Rermi[lu Constrain [ ) Repair t..�Id made ( I Abandon I i - pci,mplete',wren, ❑Indlcldual Components
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Type of Building: S;nile Ygr„iy
Dwelling—No.of Bedrooms 3
Other—Type of Building No.of persons
Other fixtures
Lot Size Sq.feet
Garbage Grinder (NO)
Showers ( ). Cafeteria ( )
Design Flow(min.required) 330 gpd Calculated design flow 330 gpd Design flow provided 432 epd
Plan: Date Mara. Ib, 7007 t Number of sheets i Revision Date
Title _ -es,4ye Di5pos4l ..y54et.n llepaiof-
Description of Soil(s) -o $=ii Hal . F r+^ t\
Soil Evaluator Form No. Name of Soil Evaluator M1 riles-e Sets Date of Evaluation on-l(t, 7003
.,
DESCRIPTION OF REPAIRS OR ALTERATIONS P. Mc ET,-IA,
f?vp;ace c9n-1✓e <Y34enl , )¢e ela■■
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
MU 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by of Health.
Signed
Inspections 1
Date
FORM 1 - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
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No.
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THE COMMONWEALTH OF MASSACHUSETTS
Nor4bar.p-ht, BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: E] Individual Componeftl(c) U+ Complete System //_ /
The undersigned hereby certify that the Sewage Disposal Systcm!COns[ructed
( ),Repaired(1�. Upgraded(I/),Abandoned( )
by: 1129'1 F lir) -7th A%7D /l-rw{.e� '.H /.tl!!/ /( ,, ,�.Y �/> S —$/...1
at c( I -tu�� V'..°yam `J�r.� - rn9--y /Arch y, GZt?In
has been installe in a rdance with the provisions of 310 CMR 15.00 (Title 5) and the approved desi fans/as-built
plans relating to application yo. . dated pal VIC,i 'f t7.CD-3� Approved Design Flow (gpd)
Installer 5.
i 0
Designer: may f ronj)�(%*3 Inspector 7 ' ���.I� .� to
The issuance of this certificate shall not be construed as a gu an -e`iptst e syste ll tion as signed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
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No —! " THE COMMONWEALTH OF MASSACHUSETTS ✓< F>=B
�kJcr4iani fz n BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( \) Upgrade (_ ) Abandon ( ) an individual sewage
as described
disposal system al 1/-`
in the application for Disposal System Construction Permit No
Provided: Construction shall be completed within three years of the date of this permit jAU}locaU,conditions aiiisrbe met.
Date i - " v — Board of Health /t' f
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255(REV 5/96)
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PUBLISHERS- BOSTON