595 Application & Permit 2006 THE COM MON#EA LTH OF MASSACHUSETTS Pee
BOARD OF HEALTH CI<
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OF
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
lication fora Permiuu Construct � Repair (p5 Upgrade ( /Abandon ( ) - ❑Complete System ❑Individual Components
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Type of Building: a-"u t" t` •
Dwelling—No.of Bedrooms L'
Other—type of Building
Other fixtures
Design Flow(min. required) 5)c) gpd Calculated design flow ' ;'J gpd Design flow provided %33 gpd
Plan: Date I X• b Number of sheets 1 7 Revision Date
Title 1 'd .t . . k yo-vim
Description of Soil(s) r'
Soil Evaluator Form No. "rte'! Name of Soil Evaluator , r _ :.-LDate of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS i
No. of persons
Lot Size Ik 7 - Sq.feet
Garbage Grinder ( )
Showers ( ). Cafeteria ( )
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Lot
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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 system in operation until a Certificate of Compliance ha been' uedyby the Board of Health.
Signed - - . 21.0'- r-=` • Date / / (
Inspections
FORM I - APPLICATION FOR OSCP DEP APPROVED FORM 5/96
No. THE COMMONWEALTH OF MASSACHUSETTS Far
Pit (F/ rfa.P "f BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work Individual Component(s) D Complete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired(X),Upgraded( ),Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated . Approved Design Flow 5 3 i (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.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( y Repair ( s./j Upgrade ( L.-I/Abandon ( ) an individual sewage
disposal system at - , ,( <(A as described
in the application for Disposal System Construction Permit No. _-.. !r
dated
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met.
Date / '// �'L Board of Health - -- - - -
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 1 REV 5/961 (II&WW HOBBS&WARREN "
PUBLISHERS- BOSTON