101 Applications & Permits No 6/-7522
THE CO MM..NWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
it✓'
rta —
DISPOSAL SYST M CONSTRUCTION PERMIT
Ions ct ( ) Repair (x) Upgrade ( ) Abandon ( ) an individual sewage
P/2-7
Construction Permit No. 0/7 5—
Permission is hereby granted to
disposal system at /D / O//r
in the application for Disposal System
dated
Provided: Construction shall be completed within three years of the date of this permit I�+a
Date
/t' Lr"
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 12551 REV 5/351 ETETV) Hoses d WARRENTM
Board of Health
PUBLISHERS - BOSTON
as described
con U10[is
met.
THE COMMONWEALTH OF MASSACHUSETTS
BOARDS OF HEALTH
'Thy OF /SAO 1--L I tve1 4'
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
oncros
Application for a Permit to Construct ( ) Repair ()C Upgrade ( ) Abandon ( ) - Complete System ❑Individual Comp
161 016L FiLanar y MA of
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idep
6 olCOiL-F4- hd „O n p
c S" ._c*-a26
lJaplpmct
i 1<N� Lot Size Sq.feet
Type Dwelling li g—No. �'����`y"'
3 Garbage Grinder ( )
Otheri--No.ofuild ng No of persons CO Showers ( ). Cafeteria ( )
Other—Type of Building -
Other fixtures
Design Flow(min. re luire ) '�Q O BP
d Calculated design flow gpd Design flow provided gpd
Revision Date // —/2 —43
Plan: Dat 0 0 e s Number or sheets 14.4i5_081` —
Title We._ 4._ -p r .O . • _ �.,
Description Evaluator Soil(s) .- s • — - pyw-p_Date of Evaluation 09 —,29-03
Name of Soil Evaluator(a
Soil Evaluator Form No. .V/ff / / ' _ /
O —
DESCRIPTION OF REPAI S OR AaLT(ZATI / /► le n w //O.A—y
r-
Tse undersigned agrees to install the above described Individual Sewage Disposal l Sn t m i bacc irdanc by iwith the pprovisions of
T U 5 and further agrees not to die system in operation until a Certificate of Came t
Inspections
FORM I - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
THE COMMONWEALTH OF MASSACHUSETTS
C60 15-Pi BOARD OF HEALTH
iii CERTIFICATE OF COMPLIANCE
Description of Work: ❑
Individual Component(s) plete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired pgraded(Abandoned( )
iwc
by:
at -_
has been/installed in a ordance wl gut e prov on r I tt (Ti i �) and t Design Flow
plans/as-built
plans relating application No. T/ ts� dated �;.c�
P ^_ I 1��W l�� • c- In
Installer
V
Date
Designer / s,„/
�--- Inspector / ]' %!
ry� tl '�
The issuance of Ihis%rnfiCro shall not be construed as a g{Yatdhtee that the system will function as s ed.
FORM 3 - CERTIFICATE OF COMPLIANCE
DEP APPROVED FORM 5/96
No. (7/- /_'.,0 THE COMMONWEALTH OF MASSACHUSETTS FEE
1
4/44117)42°./ BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Cons,tfuct ( ) Repair ( Upgrade ( ) Abandon ( ) an individual sewage
I - I t as described
disposal system at if � I ( f� �/� � � �.
in the application for Disposal System Construction Permit No. O/—/ 5/l; •dated / u% j
Provided: Construction shall be completed within three years of the date of this perm¢ All'peal con,ions m j E met_
Date / Board of Health /Ls yiidr cC':-.71'
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 1 REV 5/961 ( HEW> HOBBS&WARRENT"
PUBLISHERS-BOSTON
No O/-15 f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FE F
/Owls OF /Jot i%Y n 1fl'
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ,) Upgrade ( ) Abandon ( ) bsVComplete System ❑Individual Components
&MALY)Hat- gPheOCa bit;ai-
nnner'Na C
Map dvawr.
Lot
lost
Other—Type of Building
Other fixtures _
Design Flow(min. required • gpd Cale lated design flow gpd Design flow provided317.3 gpd
s Revision Date
5 G 0� Number of sh -I �.
Plan: Date 5 .*e — C* &
Title Se chi
p&
2111 I .�
(s) Name O Soil Evalua le _+a.- Date ofEvaluation •- - 9
Amr
Taepn
7 -.35'/- 43G,R
Of
fume
n
Ti] hoc
..gi n¢, rr.a
Jar
nn 7&CO
Tele&
Lot Size Sq.feet
Garbage Grinder ( )
No.of persons Showers ( ), Cafeteria ( )
U%%
Type of Building:
Dwelling—No.of Bedroo ms
Description of So
I
DESCRIPTION OF REPAIRS OR ALTERATIONS 'O t/VS ra(A vin • hl� '!
(A) i+/-) GAPAAl- Ida
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'ssued by the Board of Health.
Pc" „ Date 42/0/
Signed
Inspections
AMVIWASEGIP
FORM t - APPLICATION FOR DSCP DEP APPROVE FORM 5/96
No.
Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) ❑Complete System
EFT
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired( ),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 (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
Noi /
THE COMMONWEALTH OF MASSACHUSETTS
/OR{6C&4'^7141Z'BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEL/
Permission is hereby granted to Constryct (..„...4 Repair ( Upgrade ( ) Abandon ( ) an individual sewage
disposal system at / C I (../c1 t4 4 t—7 .C.
as described
in the application for Disposal System Construction PevmiNo, L /- /i dated / // )5/( /
Provided; Constructio shall he completed within three years of the date of this pen ocaJ cyndittoRS���ust be met.
Date ( // 5'G / Board of Health A'` <.A ((:',VIA'''. Fes=`S-^—> t
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 1 REV 5/96)
MIND HOBBSa WABBCN'"
PUBLISHERS- BOSTON
COMMONWEALTH'OF MASSACHUSETIS
Board of Health, />�i'I/771•//11/1
VIA
FEE setia
PLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Coautnra y) Repair(✓) tipgrade( ) Abandon( ) - C3-Gromplete System
U Individual Components
I, Location /0/ Qom/ Pl/1,e/ P-04,0
D
Owner's Name , /L /Pk/
,t LU
Nap/Parcel# �e,9/414 /jO A
X1/1
lo/ ate /-F• 22 %).10
Address y
Lot# �/ QLQ �A2�
��
Telephone# �O2"7J7��/� iB' —
c'a/ z c-/— R,
Installer's Name
.P/refex/4
Designer's Name All C 4 79
Address
Ali
Address 5,0 O.D / //6/ Ed
Telephone#
Telephone# /IC L(/p/LQ A--141
Type of Building 5 1 C/&of_ ,C,9ry1/e c i/e
Dwelling-No.of Bedrooms t/ O D/1o0 �
Omer-Type of Building � D/S/GOS�/L Fa'G
Other Fixtures
Lot Size £-i/ r s fsq.h_
Garbage grinder(4� %/'
5�T No.of persons ea Showers (l,cafeteria (Ale)
Design Flow (min.required)//O 7 3 'Y/Sl%pd Calculated design flow
/En
Plan: Date c r ® /9 99
Title
Description of SoilN)
Soil Evaluator Form No. //
Number of sheets
417S- Design flow provided IS 0 V gpd
'42
Revision Date
/Z•
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Esaluator/,o�o(+%s/4/24,1 ate of Evaluation
Z�
E £ r///-t
c
cla �/' a. FA-/enc
SyJ 6v:rm
The undersign es to install jbe ayavg dese/19ed Individual Sewage Disposal S
Further agrees to A to place the stj•$dt op ft 4on until a Certificate of C
Date
Signed x
SoPta9
/999
re,4 7C
em in accordance with the provisions of TITLE 5 and
en issued by the Board of Health.
Inspections
COMMONWEALTH Of MASSACIfJSETTS
. MA.
CERTIFICATE OF COMPLIANCE
FEE
>scription of Work: 7 Individual Component(s) ❑Complete System
to undersigned hereby certify that the Sewage Disposal System; Constructed ( ).Repaired ( ),Upgraded ( ).Abandoned ( )
is been installed in accordance with the provisions of 910 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
tplication No. dated . Approved Design Flow (gpd)
smiler
esigner: Inspector: Date:
Ile issuance of this permit shall not be construed as a guarantee that the system will function as designed.
y�y� t, /° /7f
COMMONWEALTH OF IASSACITL'SETTS
Bomd ofllealth, a ✓�
MA.
DISPOSAL SYSTEM CONSTR CTION PERMIT
JC)
FE 30
crmission is hereby granted to; Construct(� ) Repair( 1-)--<�'ade( ) Abandon( ) an individual sewage disposal system
0 ) l%/J re p� /=tX as described in the application for
isposal System Construction Permit No. 1/q—Y,. dated /C/a Slf5 ¢¢¢
rovided. Construction shall be completed within thr eeyyears of tie date of this per All or con���y'o s must be met.
m 1255 ero.5196 am.SuRin Co susior MA Date /// 2 Board of Health G "/.N