50 Application & Permit 2006 Nov,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C tri 0 F NoRT irrofJ
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
't- t1 '!.1-
•pair Upgrade t 7 Abandon 1 - Complete System ❑Individual Components
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Type of Building: l N bec.
3
Dwelling—No.of Bedrooms
Other—Type of Building
No-of persons
Lot Size Sq.feet
Garbage Grinder (NC)
Showers ( ). Cafeteria ( )
Other fixtures
Design Flow(min.required) 39) bpd Calculated design floss:�"' _gpd Design flow pravided3/C J gpd
Plan: Date DV. _ i-S Number of sheets Revision Date
Title - ' YF". . ij 61.,13 ILL So/.9 ball.
Description of Soil(s) -n t"( A�Df/ rf,���
Soil Evaluator Form No. l Name of Soil Evaluator T Y✓ /uIV/1 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Ott C L7C %%i/fl/G
AND
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 up it a Certificate of Compliance has been issued by the Boar Health.
n / Date_ (P7_L
Signed 1��
Inspections 1111
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
Description of Work:
The undersigned hereby cer
bp:
at
has been installed
retain t1 application' b
Installer 7-. -�
THE COMMOI1 WEALTH OF MASSACHUSETTS
'r1/21 / /%/gy./42BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
omplete System A vz
0 Individual Component(s)
that the Sewage Disposai.System:Constructed( )-Repaired(cif. t)pgraded(✓f Abandoned(
I, . hfl _ i
U/„c�
Iled in accordance
with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
. f---VI dated /i 1‘11:1 //o ` . App1oved Design How (gpd)
Cd i 1
l n f
t �
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. '2545 - '//
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
HEALTH
FHE -
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( /Upgade ( ) Abandon ( ) an Indi
disposal system at
in the application for Disposal System Construction Permit No. -rf A � - � r .dated -
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must he met.
Board of Health
2
dual sewage
as described
Date i ..
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 IREV 5/96'
SHAW ) HOBBS&WARREN'u
PUBLISHERS - BOSTON