255 Application & Permit 2005 No, - O pj THE COMMONWEALTH OF MASSACHUSETTS FEE [5-3,0)
V BOARD OF HEALTH
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct (V Repair ( ) Upgrade ( ) Abandon ( ) ❑Complete System ❑Individual Components
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Type of Building: ht_LZ�I 9 na)1
Dwelling—No.of Bedrooms 4
Other—Type of Building
Other fixtures A-
De ign Flow(mi-t.r 4uir d) gpd Calculated design flow gpd Design flow provided gpd
Plan: ate 3 (� O� Number of sheettssr 1 n _Revisipn Date
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Description of Soil(s) %MJ U t crA,A. av 512 nvtc61.4.4 S rtNJ () I �j ra"tOLPrp i f
Soil Evaluator Form No. ii $ 1'2 Name of Soil Eva
( ';to'r�M ,, t0"14)igJ Date of Evaluation 3I bZ
DESCRIPTION OF REPAIRS OR ALTERAT IONS IJta/ £Ozi c�-ut17c* i - 1(JC.4-1, eSI
Lot Sizeci;.a T Sq.feet
Garbage Grinder ( ✓j DE5ICJJ Pet 0,0 1-1
No.of persons Showers ( ), Cafeteria ( ) Q6bf'
The unders
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Signed
Inspections
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rees to install the above described Individual Sewage Disposal System in accordance with the provisions of
not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
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Date
05- ✓.�. • ,/LL ' s h '
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FORM 1 - APPLICAT
ON FOR
DSCP
DEP AROV D 'ORM5/96 ( i/
No.c)S —O8
t
THE COM ONWEALTH OF MASSACHUSETTS
OC`= :% BOARD OF HEALTH
CERTIFICATE OF CQMPLIANCE
Description of Work: Individual Component(s) Compleej System
The undersigned hereb•tern y that the Sewage Disposal System:Constructed(✓),Repaired( ).Upgrfded( ),Abandoned( )
0 e�
by:
Ffl30•06
at
has been installed in , dordance with the rovisions o' 3 1
plans relating to application No dated 3
Installer YYJ
CM
Ik
m
(r
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15.00 (Title 5) and the approved design plans/as-built
. Approved Design Flow r/y(1 (gpd)
Designer: G(c c t ce A)E.M/✓l Inspecto
The issuance of this Vica,*shall not be construed as a guarantee tha the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
Date 77241 3i 5..
No. 26 7) 4---cog.
THE COMMONWEALTH OF MASSACHUSETTS
7 27/endet6 BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construe ( Repair � )
disposal system at
in the application for Disposal System Construction Permit No. 0-06 C
is permit. All local conditions must be met.
U;grade ( - ) Abandon
6 !
an idual sewage
cribed
.dated d3 7e/Qs--.
Provided: Construction shall be completed within three years of the date of th
Date
FORM 2 - DSCP
FORM 1255 (REV 5/96)
DEP APPROVED FORM 5/96
H&WD HOBBS&WARREN 1M
Board of Health
PUBLISHERS-BOSTON