263 Application & Permit 2003 iN-03
THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
C I T`r OF Uo TZTFiMAP1t
APPLICATION FO"R DISPOSAL SYSTEM CONSTRUCTION PERMIT
kw-) Re yr [ ) Up€rude ( ) Abandon ( ) - omplete System ❑Individual Components
Application tor Perms io CAn Ll W. r'
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Type of Building: IZe51DBe177 Al-
Dwelling—No.of Bedrooms Ss/r5."
Other—Type of Buiidio N//} No.of persons
Other fixtures Ai A
Design Flow(mi .re uired) 5S1/ gpd Calculated design flow 557 gpd Design flow provided 33Z) gpd
Plan: Date Z
03 Number of sheets I Revision D to
Title SeidatCE i.SRa- v57e-AA AT /or nu SYLyrswe /20� a¢YN/NHPre+✓, MA
Description of Soil(s) SNEE1 LRAM 7D/I SW ore z SNwOS ✓94t4/4../ SSG P4-,40l
Soil Evaluator Form No. // f/Z. Name of Soil Evaluator 44 . 7Z/D44FYdA/ Date of Evaluation $ -20-02-
DESCRIPTION OF REPAIRS OR ALTERATIONS NF G ' M4- c%7'� /NG[.-1063
iSDD-r9TloAl sFn;c ; r✓K D-BOC 7�O Ail LOA * 4 t.0,06 x z DE
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TIIIF 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Date
Lot Size t.'s i A°x+Y feet
Garbage Grinder (✓)
Showers ( ). Cafeteria (
Signed
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
oIo27
THE COMMONWEALTH OF MASSACHUSETTS
/ 4)Z'7l%Sn 2/ 0ARD OF HEALTH
CERTIFICATE OF COMPLIANCE
lescription of Work: ❑ Individual Componeni(s) IV Complet ystem
he undersigned hereby certify that the Sewage Disposal System;Constructed( ,Repaired( ). Upgraded( ),Abandoned( )
y: "Kb l A-v,& LC. . S yc z;EfteA p e721kitlifrwil 41i -695=4
t /uiSt Lea - U/0 JY� (7al %Lff du, o(1> fi.
as been installed in hccordance with the provisions of 310 C R 15.00 (Title 5) and the Design d design plans/as-built
�-built
tans relating to application No. /ti L 3 dated L//)8�0 -3 .
nstaller - �_ /n:/i� i-' / /
ate 0// ?/ R..3
FEE /7245 11
)esigner. / /C - Inspector
/Pi
The issuance of this certificate shall noTbe construed as a gun
'ORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
'ntee that the system will function as designed.
No. 4d. 6
_11/17
THE COMMONWEALTH OF MASSACHUSETTS FEE
\is i2I�7Q I7Jh$ BOARD OF HEALTH
,/
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby ranted to construct ( eda r (
disposal system at ),3 QQJiA-P H .ti. 9,
in the application for Disposal System Construction Permit No.
Provided: Construction shall be completed within three years of the date of this perryit'lA
J'/
Date I / 3 Board of Health 11//
FORM 2 - DSCP DEP APPROVED FORM 5/96
Upgrade ( ) Abandon ( ) an individual sewage
i Y9id-n .) G tt I !U- as described
/c/-'93 .dated S y 3 •
FORM 1255 1 REV 5/96)
2)--ISW Hoess&WARREN iM
PUBLISHERS- BOSTON
ocarcon Lions
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