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101 Applications & Permits Vn i THE COMMONWEALTH OF MASSACHUSETTS ,'It BOARDS %OF OF H C---Ay---j O F Aia•- �- APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application tar a Permit to Construct ( 1 Repair tgl Uperu e ( 1 - T ki D a 10Y3,0 x' _ ©K D0 t.3 ill\Ar - — LTA --- — r�h✓:::::: '''n 99-1, �hC .fihJTA uLnu --- r Telephone Telephone n ,` Lot Slzc Sq. feet Type ong Building: C-drbo�fieIn Garbage Grinder ( ) Other_-Type of Building In �'-"a-g- tat No.of persons_..CO � howers ( ). Cafeteria ( ) Other—Type o[F3ulding_ / Other fixtures gpd Calculated design flow gpd Design flow provided,A I gpd Design ate (min requ red)�e2-U gN ax i6 t Revision Date N h - �43_ Number of thee-fi-"_`_�� .fir � as Plan: Date_1440 1�j,A) .— - Title ... a •-__ �I a h..v �,3�= .�r .Tn,. crt. i H --e-e7-.6 — Soil F tion of Soil(s) (* to oflivaluation LO --..// O �� LV Name of Soil Evaluator 1Vx r� Soil Evaluator Form No. �—� �- 11� N. /S . og /0 �41 e- 4 °`s_. DESCRIPTION OF REPAIRS r7S-r ZQa� (` „1_ei-r The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of ITU 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. -2:7'r- O� Inspections FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CERTIFICATE OF COMPLIANCE )escription of Work: ❑ Individual Component(s) ❑Complete System Die undersigned hereby certify that the Sewage Disposal System'.Constructed( ).Repaired( ).Upgraded( ).Abandoned( ) ht has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5)APPr the veJalJesign Flow design plans/as-built plans relating to application No.— dated_ Installer Datc _Inspector Designee The issuance of this certificate shall not be construed as aD9EP APPROVED SFSO FORM 5/96 man as designed.that the FORM 3 - CERTIFICATE OF COMPLIANCE No. fir' - ,-5:‘ THE COMMONWEALTH OF MASSACHUSETTS FEE 4 ? i 144 ' BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT 1na nal sewage rade ( handon (/ ) Permission is hereby granted to Cogstruct (/ ) Rcpair�( Upg �.. t/ as described disposal systcm at // � � 7 L(g_C �j dated in the application for Disposal System Construction Permit O. - n(ny�t be met. Provided: Construction shall be completed within three years of the date of this peI.M loco cood !1- i/ Date — G ! �tZ'�j Board of Health � —��—� FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 12551REV 51951 l&W HOBBS&WARREN M PUBLISHERS-BOSTON in. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF APPLICATION FOR DISPOSALSYSTEM CONSTRUCTION PERMIT Vppfleation for a Permit to Construct 00 Repair t 1 t:pgrade t 1 Abandon Type of Building: Locr,.,,, >i„o rvnr.0-i- Ls—terenk- err. -S'B�r - G3 /0/ O/ Fev r,mr,,,. � H03 -s�,t=s-a�a Tee na„wr Lot Size Sq. feet oms — )- Cafeteria ( ) Othcr—TVpe of Building N o.of persons— of Garbage Grinder (V� Shoryers Dwelling Type of Bedro Other fixtures - /� K e d Calculated design flow_gpd Design[low provided Z�gpd Design Flow(min.requi red)SpSit-- P f YrXie9 r Revision Date A _Number of sheets Plan: Date //—/ -, ��_ Title - • - ” aA n_r PA.wGLL�V I '� Desalpuon of Sol(s)�d _ �Dav [Evaluation t3 9� Soil Evaluator Form No. a /p Name of Soli Evaluator 0— - DESCRIPTION OF REPAIRS OR ALTERATIONS- Inspections_ —— install the above described Individual Sewage Disposal System in accordance with the provisions of The undersigned agrees to TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. J2rt of - FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 N No. /j Description of Work: The undersigned hereby by:- at THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CERTIFICATE OF COMPLIANCE 0 Individual Component(s) ❑Complete System certify that the Sewage Disposal System_Constructed( ).Repaired( ).Upgraded( )-Abandoned( ) Fri, has been installed in accordance with the provisions of 310 CAM 15,00 (Title 5) and the approved design plans/as-buu t plans relating to application No. dated Installer Date The _ Inspector Designer: Th issuance of this certificate shall not be construed as AD9EaPraAnP that APPROVED 5/96 function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE l No. fr r�- THE COMMONWEALTH OF MASSACHUSETTS i(nvt' kAdij BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT on an individual 1 t -f 1-3 .rte Ts, FE grade ( and ( ) ndividual sewage Permission is hereby granted to Construct (� - -Part ) lip grade ) as described disposal system at - /C� .dated i//—j -. v -:, in the application for Disposal System Construction Permit No. '1 , Provided: CopIllm urusIcompleted within three years of the date t t this permyrpol cal co dMons must. /Ai+-c-i //- -,7 }-CJ Board Health_ �� Date_ a FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 1 REV /961 ', FIFE: HOBBS&WARREN r" PUBLISHERS- BOSTON