41 Applications & Permits 3s�
THE COMMONWEALTH OF MASSACHUSETTS
rr�� BOARD OF HEALTH
l.�lial OF t iOtfl4A-MRT0 i3
LPPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
li .lir 1 's r'P°rude f ) Abandon t ) - Complete.System Rildis idual Components
rlicotion tor a rcrmn to. mist uu t ) �l -
`,e tLed 1� 5i-tna.f 53 4FA
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1B -335 - saga
Tel Feune 4
TdepMmc�
010 bo
c of Building: Res:BFisrift i— Lot Size�3"T t Sq fceett �� �.��_�
elling—No.of Bedrooms 3 Garbage Grinder (hi)+-
ter—Type of Building No.of persons Showers ( ). Cafeteria ( )
ter futures A �
sign Flow(m r ✓3(J .fired) gpd Calculated design flow 330 gpd Design [low provided 3 D gpd
n: Date 7 2e 8 Number of sheets 1 Revision Date
le _._.e_ • .0 . Si —sL Re'nn¢ Fog Ay1 CCO t�Q-1 QeAO�ivA¢THAwW i
scription of Soil(s) -59fdD4 (Y-M /TJ W LO t I OS - See (1.+i t-
it Evaluator Form No. 11 4 12- Name of Soil Eva^luuaator�-_LtL/C° 6 Date of Evaluatioofll( q6
_SCRIPTION OF REPAIRS OR ALTERATIONS K 6 s-E-0 L H F
D+. F (' seo s — FI el.-C1 FlN b At I. • _1a ' .t "su =r,
icutn Ptlesc; cnAr
{kjG.Is lc > ti att-..l SJS'f'filft
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
U 5 and further agrees not to place the system in operation until a CerKBcete of Compliance has been issued by the Board of Health.
� t Date ? Nth,
toed
spectians
ORM 1 - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
ption of Work: ❑
Individual Component(s) ❑Complete System
Idersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired( ).Upgraded( ).Abandoned(
een installed in accordance with the provisions of 310 CMR 15.00 (Title 5)) and approved design plans/as-hg up t
relating to application No. dated
FrE
Ier
Inspector
he e issoanse of this certificate shall not be construed as aOgEPaAPPROVED n SFOR M 5/96 function as designed.
M 3 - CERTIFICATE OF COMPLIANCE
Date
�
35--S!/ THE COMMONWEALTH OF MASSACHUSETTS Fee J v
aH I'd BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to C.nstruct ( ) Rep�r�(X Upgrade ( ) Abandon ( ) an individual sewage
J is described
73/ F
vided: Construction shall he completed within three years of the date of this permit. Aline L.on iti ns , —..____
osal system at -93-- ,dated
re application for Disposal System Construction Permit No.
aFr- cg
RM 2 - DSCP DEP APPROVED FORM 5/96
PUBLISHERS- BOSTON
3M 1255 (REV 5/96) A H&W ) HOBBS&WARREN
Board of Health
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF__V
FEH. !.L..67/
Appliratimt inr Bispuoal 31harks wnczstr�utrtinn Prrmit
alication is hereby made for a Permit to Construct ( ) or Repair (' ) an Individual Sewage Disposal
at:
or Lot No.
Address
Installer Address
Installer U Size Lot Sq. feet
f Building Expansion Attic ( ) Garbage Grinder ( )
yelling of Bedrooms Showers ( ) — Cafeteria ( )
:her—Type of Building No. of persons
Other fixtures gallons
Flow gallons per person Depth
Tank—Liquid capacity �a Total Length
Total leachtng area sq. ft.
al Trench—No. Total leaching area sq. ft.
;e Pit No
Distribution box (
ation Test Results
'est Pit No. 1
'est Pit No. 2
er day. Total daily flow
Mons Length Width Diameter
Width ota
Diameter Depth below inlet
) Dosing tank ( )
Performed by
minutes per inch Depth of Test Pit
minutes per inch Depth of Test Pit
Date
Depth to ground water
Depth to ground water
iption of Soil p
re of Repairs or It aeons— sorer when a plicab M'°�•'�^�
a l l-I t
The undersigned agrees to install the aforedescrihed individual Sewage Disposal System in accordance with
rovisions of T=Ti✓ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
pion until a Certificate of Compliance has been sued by the board of heglth.
r.
lication Approved 13y
lication Disapproved for the following re TS
Permit No..-6T-' �
D '.101
Date
Issued...
mt
7_4-x-7/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
GCrrtifiratr of Qlumpliatur
HIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
en installed in accordance with the provisions of TITLE
ation for Disposal Works Construction Permit No
rHE ISSUANCE OF THIS CERTIFICATE SHALL NOT
EM WILL FUNCTION SATISFACTORY.
lc Inspector
5 of The State Sanitary Code as described in the
dated
BE CONSTRUED AS A GUARANTEE THAT THE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Eisposi$ i:r'irks Olunotrurtinn jrrmit
Permission is hereby grant d-. l
Instruct ( ) or Repair (I ) anjndividual Sewage fsposal System
Far
0 r so-.et
own on the application for Disposal Works Construction Permit No.i
Dated'..
Board of Health
'E
1255 HOBBS & WARREN. INC.. PUBLISHERS