6 Cedar Hill Road Septic Tank Plan 1-10-2019 ` J Commonwealth of Massachusetts
City/Town of Salem Number
A = Application for Disposal System
Construction Permit Feo.00
Form 1A
DEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Important:
When filling out Application is hereby made for a permit to:❑ Construct a new on-site sewage disposal system
forms on the ❑ Repair or replace an existing on-site sewage disposal system
computer, use
only the tab key ® Repair or replace an existing system component
to move your
cursor-do not 1. Location of Facility:
use the return
key. 6 Cedar Hill Road
Address or Lot#
Salem MA 01970
City/Town State Zip Code
2. Owner Information
Cheryl Winter
Name
Address(if different from above)
City/Town State Zip Code
978-290-0195
Telephone Number
3. Installer Information
Jonathan Granz Preventative Septic
Name Name of Company
46 Beech Street
Address
South Hamilton _MA 01982
City/Town State Zip Code
978-468-9001
Telephone Number
4. Designer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
N,
City/Town of Salem Number
Application for Disposal System
- $10.00
Construction Permit Fee
Form 1A
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check if present)
Other: Type of Building - Number of Persons Served
❑ Showers Number of showers ❑ Cafeteria ❑ Other fixtures
Specify other fixtures:
6. Design Flow: Gallons per Day
Calculated Daily Flow- Gallons
7 Plan: Date of Original
Number of Sheets Revision Date
Title of Plan
8. Description of Soil:
9. Nature of Repairs or Alterations(if applicable):
Replace broken pipe from septic tank to soil absorption system, install PVC outlet tee in septic tank.
10. Date last inspected: Date
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
v Commonwealth of Massachusetts
City/Town of Salem Number
Application for Disposal System
$10.00
Construction Permit Fee —
Form 1A
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and
not to pla the system in operation until a Certificate of Compliance has been issued by this Board
of Healt .
Sign ure Date
Ap cation Approved By:
Name Date
Application Disapproved for the following reasons:
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