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No. ,THE COMMONWEALTH OF MASSACHUSETTS FEE 's
BOARD OF HEALTH
—OF �LZA#ZVV1Q%A7V%
APPLICATION FOR ISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct (Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System ,individual Components
CA --I -Zclal�-
Location
Map/Parcel #
Lot #
131v7Q_ Wc�4.e'2_
Installer's Name
5 v Itit K .ti re
k&2. y u� n., . ,i�►
Address
7 O 0
Telephone #
/4 KA
3s` I..cAua„-,,_k
Owner's Name
s-(-Qe-+ Lacsf Gy,410-n
S0% - ZLO -
Address
'3(041
Telephone #
DcA&Q-eA 1AAt_.,I.o.A-
Designer's Name
4.6+ su�l�. �k
Address
3&
2Cc 22
Telephone #
Type of Building: 1), t O1” Lot Size I t) 1-20, Sq. feet
Dwelling — No. of Bedr oo ms L.. Garbage Grinder (til)
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures.
a
Design Flow (min. required) ! 10 gpd Calculated design flow I-IL40 gpd Design flow provided bpd
Plan: Date %/ 0 4f Number of sheets Revision Date
Title
Description of Soil(s) Lou ..• �l cv.l �( yC� Isvi e rJ S s .IciC
Soil Evaluator Form No. Name of Soil Evaluator LNIZate -i Imo -eie-R Date of Evaluatio r_J& Si
DESCRIPTION OF REPAIRS OR ALTERATIONS _ M00 da1.0 VA 6i 19.x. Gln"to It "._j
6W C,_2c(_ c_4 o Ul 6 CQ
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 an further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed I, A
,/�—Dyate
Incnect' c 6 " def . ln' d1, A kl %� /OP /S/f�s� , / �(
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
_---------- --------------------.--------------/--,+-----------------------
No. r THE COMMONWEALTH OF MASSACHUSETTS N FEE
V ltvVl„0�'"1 BOARD OF HEALTH d�
CERTIFICATE OF COMPLIANCE��uG� l?
Description of Work: 'pIndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (Repaired( ), Upgraded ( ),Abandoned )
by: � C?WkIkf1
at 1 rh 1 I ltfq Ct-i +VID `
has been installed in accordance with the provisions of 310 CMR 15.0Q (Title 5) and the approved design plans/as-built
plans relating to application No. dated 6-.. , - . Approved Design Flow (gpd)
Installer k v a �,OL,"� r X719 1C • ' c �" �
Designer: D90ke A� ►i e t c+r1 S Inspector i �.- , r1` v' 'C c�' �" Date _ _ _ 7-
The issuance of this certificate shall not be construed as a gyarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No.. THE COMMONWEALTH OF MASSACHUSETTS FEE
11t4l/ BOARD OF HEALTH
DISPOSA SYSTEM CONSTRUCTION PERMIT
Permission is hereby Iran ed to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at 17 °`I C 41 54— as described
in the application for Disposal System Construction Pelt No. __ CFa ' -/ i '�'�, dated '
Provided: Construction shall be completed within t *0the date of this p e�Zij. Alllocal conditions p;tu'st be met.
Date '� 1 �% Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HoaBs& WARREN TM PUBLISHERS - BOSTON