301 Application & Permit 2001 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ct+y OF eral9eripAn
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
pplication for a Permit to Construct (s.Yke pain ( I Upgrade ( 1 Abandon ( 1 - ieeticimplete Ss stem ❑Individual Components
FEE 44
Pq.ctl A - SYlves4.,- Rand
E9,,;47 1i,;telers
77 Maple s+. F(arence •iA 01062-
Addav
413 - Sfjs - eozs
20 / S YLvzs-)2 ,Z L
Nury I' rceI n
/di-'il'G if/ /[/^roQ
i-i■t t+awrx 'Ec+v ire n
C restk:J,P.O.-Box Z26 N.rtt\4 c tci
MA O1d66
Admcs.
Address
4(3 -247-5464
lacphone 4
Telephow+
re of Building: Sir-9(¢
telling—No.of Bedrooms
cer—Type of Building
ter fixtures
Fa i W¢ttin
3 I
No of persons
Lot Size t.637 Ames
Garbage Grinder ( )
Showers ( ). Cafeteria
sign Flow(min.required) 495 and Calculated design Clow gpd Design flow provided SOS gpd
n: Date 7-30-01 Number of sheets t Revision Date
e .ia r b- pawl cit4..-gx,
scription of Soil(s) Sea Soil Eva(uah. 'Sr,"S
I Evaluator Form No. Name of Soil Evaluator ■aett Bead
.SCRIPIION OF REPAIRS OR ALTERATIONS
Date of Evaluation 6124/9A 4 Chain
the undersi ned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
E 5 and b agrees not . place4 e sy in operation until a Certificate of Complian e ha issued by the Board of Health.
ced
leclioD
Date gl
RM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
iption of Work; ❑ Individual Component(s) cYComplete System
idersigned hereby certify that the Sewage Disposal System:Constructed(xl.Repaired( )-Upgraded( ),Abandoned( )
/
In / ,t( ° jt° i L" `f'
/ Su('„mac
en installed in accor ance with the provisions of 310 CM 15.00 (Title 5) and the approved design lans/as-built
relating to application No. �
y I dated I�'�� f . Approved Design Flow e-)5— (gpd)
7,
neeI�/ /e if'tlJtj t"t-1 Inspector �=.` �%<--Date --%y-T(' /
le Issuance of this certificate shall not be conshued as a guarantee that the system will function as designed.
3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
cy � THE COMMONWEALTH OF MASSACHUSETTS err"-,FEE �J
Nakilidiela6 ARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
H11115.51011 is hereby granted to construct (YkRepaircf ) Upgrade ( ) Abandon ( ) an individual sewage
al system at 3E/ -,�!)1,i,- ,p1 ..as described
application for Disposal System Construction Permit No. Y/ /—)7 -dated
led: Con ctionn shall be completed within three years of the date of this pe
e 7 1 i /O 9 Board of Health
il
1 2 - DSC DEP APPROVED FORM 5/96
1255 ,REV 5/96i
( II&W) HOBBBB WARREN""
loca c9nd
PUBLISHERS - BOSTON
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