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349 Applications & Permits N o3 No THE COMMONWEALTH OF MASSACHUSETTS c BOARD el,OF-g HEALTH � 4 of Or— ho.h.� 4.. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE A--0 atinn fora Permit to Construct ( ) Repair f\4 Upgrade ( I Abandon ( ) -momplete System ['Individual Components .r 31 . i , s u • • Ln,naon nt.Vame S. M■FIFa¢d A Atltlrcs „i a ft,- ` 01 v_.!1 ie v s f 1 / 6 Plink ICI.PhoncY F.vivD .a ..:� 3 •nt¢�._rnc, .AyJfi w 1 d �c . 10 Q .-4-0.10.p4/0. A„c1„, y 3-,ra -- Co Lo Ie ,on,0 • : ' PdQ53I sY 3 6o b teph Type of Building: Dwelling—No.of Bedrooms Up #m Other—Type of Building No.of persons Other fixtures Design Flow(min.required) 1.4 s- C gpd Calculated design flow gpd Design flow provided g?°gpd Plan: Date fog-IS`-03 Number of sheets 1,241k1oa Revision Date 'WA Title - • o .� .._� i iv- — Lot Size SA.feet Garbage Grinder ( /0 Showers ( ), Cafeteria ( ) 8 Description of Soil(s) Soil Evaluator Form No. N//i Name of Soil Evaluator/79c .CAN DESCRIPTION OF REPAIRS OR ALTERATIONS YL t r a Ilrel ti .t.� ate o Evaluation oB -/3 i s — R The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TIRES and further agrees not to p the systeem i operation until a Certificate of Compliance has been issued by the Board of Health. Signed – �5' " /44i 41E6 Date ,i/1103 I r Tnq-r,11QD g■ `l' 1 wa C0 eccnc ,\ v �U FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS Fin46/AebOARD OF HEALTH E=�— IANCE CERTIFICATE OF C01VjPI- Individual Component(s) rr� Description undersigned of Work: ( ' raded( ).Abandoned( ) The undersigned hereby certify that the Sewage Disposal System:Constructed(� Repaired pg ` Ic ' , I7 'T' r 1r�cv(-/ by- � ' // the 5) and the approved dwig plans/as-built Approved Design Flow omplete System at r' (-C has been installed in accordance with the provisions n of 3 plans relating to application No. '� Installer o f f it —r C -�„ EL Date �/ _ii - IA - Inspector . _ _Designer - The issuance of this certificate shall not be construed as°DEP APPROVED 6!6°<„O°as design FORM 3 - CERTIFICATE OF COMPLIANCE !( i No. y y" '" l THE COMMONWEALTH OF MASSACHUSETTS FEE /1 �. 7,BOARD OF HEALTH DISPOSAL SYSTS CONSTRUCTION PERMIT Repair U ra e ( ) Abandon ( ) an individual sewage Permission is hereby granted to C,� i ct ( P / Lc-, p�- as described disposal system at / C�Ci_ dated in the application for Disposal System Construction Permit No. �� s )m Provided: Construction shall be completed within three years of the date of this pemj+P;A Ica)-cogdinons pints)met Board of Health -f= / d Date FORM 2 - DSCP DEP APPROVED FORM 5/96 PUBLISHERS- BOSTON �H&W) HOBBS a WARREN'° FORM 1255 [REV 5/961 C. tJ kJ' a FEE • .COMMONWFt1LTII OF MASSAC/I-I-U'S&ITS P Board of Health, /�a%L%Hfi'h'io7 /MA. r �O/ ION FOR DISPOSAL SYSTEM CONSTRUCTION Ifrt nstruct Repair Upgrade( ) Abandon( ) - ❑Complete System)(individual Components Location 704/ if CM& tYL YRtZVCL Owner's Name 7-3 kV e c/l aye /once Map/Parcel# Jyy COGS /-1GAOok! 40 Address 399 Coc'cs "zei oov Lot# /UO/�T714/1-7714/1 Ai j? Telephone# ,(/O.CrJ/AiI%�f�GK-% %7l Installer's Name Designer's Name la,CL//q-/ri j-157.1,44,�if Address / rill Telephone# .53,9 JS/ 7 647 7L5'4/ Address Telephone# - pe of Building AS/.o4/U%/,4c `/Y/� n Lot Size CT:t 5.77/U 4.ft. l'e oe//ZaiJK/ /Uo /i a041- lC /s'U� 8' Garbage grinder(A/d S406'£C_ itanii/ No.of persons Showers(22 Cafeteria At veiling-No. of Bedrooms her-Type of Building her Fixtures sign Flow(mM..�required)//O X y gpd Calculated design flow "ea Design flow provided 1166 In: Date s.ZTJ.U.L 6tS t/pNumber of sheets / Revision Date gpd le rs419)7c sysrr l d9-e5,6/0 /cto/2 n.y ~cif(t sctiption of Soil(s) S1.4y2 72chl,0 399 CO/es v er go// teD iI Evaluator Form No. t / Name of Soil Eraluatorator Date of Evaluation 47/�J'(/e?B/rj s' i .o%-q It op '.SCRIPTION OF REPAIRS OR ALTERATIONS ✓ d E 'ti/ cis S'ys,' n /L6,1/✓!'cE/LJ'Fi /T e undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and ther agre s to not to lace e t peration until a Certificate of Compliance has been issued by the Board of Health. tied °• • `I Date-Tr^"c.''a poll pections C©MMONWEALIH 0 TIU MAS SETTS Board ofHealUy '/� � /nJ s✓ MA. CERTIFICATE OF COMPLIANCE FEE` /? iption of Work: ndividual Component(s) O Complete System / tndetsig ed h ereb ccyrtify that tie age Disposal System; Constructed ( ),Repaired$1 Upgraded/Abandoned ( ) r-'j�i SC t jjC �)%c , / ten installed�in,accccordance with the prof ions f 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to ation No. go/4-c? dated j �, Approved Design How WV (gpd) ler net Inspector:A o,:,: ��. �, Date: 'r nuance of this permit shall not be construed as a guarantee at the ry em will''4nction as designed. COMMONWEALTH OF MASSACIIiJSETTS Board of Health, .'(./(.i fhCc/+17i At/ MA DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE i,si/on is hery anted to; Construupt( ) /R�e/Pair( ljpgrade2( Abandon( ) an individual sewage disposal system 311/9 (I iii'7�S' /2G/JGW 2 ,7 l// / as described in the application for sal System Construction Permit No./6/6, -9 dated ded: Construction shall be completed wit'i n/hhree years of the date of this permit. All lost itions must be met. .aev.vss wm.swnnco.craaeswntu Date � / Board of Health X� — J. j / —_— .. iJ