567 Application & Permit No.i/906^Ie THE COMMONWEALTH OF MASSACHUSETTS
r` 1 BOARD OF HEALTH
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Application for a Permit to Construct ( ) Repair OC Upgrade ( ) Abandon ( ) - Complete System _Individual Components
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Type of Building: rt).M-Act
Dwelling—No.ofBedroom 1
Other—Type of Building No.of persons
Other fixtures
Lot Size "��� Sq.feet
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arhage Grinder 4A4
IR Showers ( ). Cafeteria ( )
Design Flow(min. required)S. gpd Calculated design flow
Plan: Date O 0`I 08 Number of sheets jiaVt`s-(e" Re
Title
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gpd Design flow provided RLV.ggpd
ision Date N/d
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Description of Soil(s) t e
Soil Evaluator Form No. At/A4 N.me of Soil EN luatt
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DESCRIPTION OF REPAIRS OR ALTERATIONS
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Date of Evaluation
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
lif1F 5 and further . -s lo place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Date 09448
Signed
Inspections
FORM 1 - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
a f'� FEE
No. THE COMMONWEALTH OF MASSACHUSETTS
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Nov-ipe , ! THE/COMMONWEALTH OF MASSACHUSETTS FEE 9 /
. �4j[Ty1(FFIAO: vv BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby ranted to Construe{ ( ),Repair,( ) Upgrade ( ) Abandon ( ) an individual sewage
Ve I P---r- as described
disposal system at _ {f/t /Og
in the application for Disposal System Construction Permit No. �/�
P.- 1 t _,dated_ /
Provided: Construction shall be completed within three years of the date of this permit. II local conditio6 sr s� t be met.
• Date
-.-f7' :15 )//� Board of Health ?k
FORM 2 - OSC DEP APPROVED FORM 5/96
FORM 1255 (REV 5/961 &W� HOBB66 WARREN T"
PUBLISHERS-eOSTON AA