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HomeMy WebLinkAboutApp-Permit-ComplianceOoV 7,L NO. !G� THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade X ) Abandon ( ) - ❑ Complete System ❑ Individual Components S jis 4, `,_4, /Zl( / Location Map/Parcel # /C fns IlgrsName Address Telephone # ,,ec .4 Owner's Name Address Type of Building: I1eS Lot Size / 7`4? ySq. feet Dwelling — No. of Bedrooms Garbage Grinder ( ) Other —Type of Building No. of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow (min. required) 35, gpd Calculated design flow 3 3 v gpd Design flow, provided 3 gpd Plan: Date /�� Number of sheets / Revision Date Title rcx v,7 -w--- f- sA1 Description of Soil(s) Jam---� Soil Evaluator Form No. Name of Soil Evaluator - ©AXA Date of Evaluation SS DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fur a rees not to place system i operation until a Certificate of Compliance/has b n issued bQlr the and of Health. Signed Dat( Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ----------------------------------------------------------------------- No. r� ��6 TI-lK COMMON EALTH OF MASSACHUSETTS FEE �Piydt� BOARD OF HEALTH ,y��Z•- CERTIFICATE OF COMPLIANCE G Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: / edIle' / _ at s f 1-5 A / V G- 13x06.. has been installed in accordance with the pr visions of 310 plans relating to application No. —1b3 dated 7` Installer—P4 P4 Tr?h—' /­r'G Designer: /}Jell/,&/ /�-�'�- Inspector _ The issuance of this certificate shall not be construed as a W. CMR 15.00 (Title 5) and the approved design plans/as-built —1IP Approved Design Flow _(gpd) /_G_ FORM 3 - CERTIFICATE OF COMPLIANCE DEP 2. t/1011ti^1idate —/--�& ^ /4 the system will function as designed. 'ED FORM 5/96 No. �o -ZC7� THE COMMONWEALTH OF MASSACHUSETTS FEE /` � j&,07/Y,7,2-1 BOARD OF HEALTH G 43��Z DISPOSAL SYSTEM CONSTRUCTION PERMIT ...:.....:.... ... Permission is hereby granted to Construct ( ) Repair ) Upgrade ( icf Abandon ( ) an individual sewage disposal system at S /`_/5 h z 4ti lr �iC�00 %.rr70 $?� as described in the application for Disposal System Construction Permit No. gds G dated 7-0 — 72 Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be me, . Date %` (p — 'Fif Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON 7- Telephone # es' ner' Name 318 3 G 7 Address Telephone # Type of Building: I1eS Lot Size / 7`4? ySq. feet Dwelling — No. of Bedrooms Garbage Grinder ( ) Other —Type of Building No. of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow (min. required) 35, gpd Calculated design flow 3 3 v gpd Design flow, provided 3 gpd Plan: Date /�� Number of sheets / Revision Date Title rcx v,7 -w--- f- sA1 Description of Soil(s) Jam---� Soil Evaluator Form No. Name of Soil Evaluator - ©AXA Date of Evaluation SS DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fur a rees not to place system i operation until a Certificate of Compliance/has b n issued bQlr the and of Health. Signed Dat( Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ----------------------------------------------------------------------- No. r� ��6 TI-lK COMMON EALTH OF MASSACHUSETTS FEE �Piydt� BOARD OF HEALTH ,y��Z•- CERTIFICATE OF COMPLIANCE G Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: / edIle' / _ at s f 1-5 A / V G- 13x06.. has been installed in accordance with the pr visions of 310 plans relating to application No. —1b3 dated 7` Installer—P4 P4 Tr?h—' /­r'G Designer: /}Jell/,&/ /�-�'�- Inspector _ The issuance of this certificate shall not be construed as a W. CMR 15.00 (Title 5) and the approved design plans/as-built —1IP Approved Design Flow _(gpd) /_G_ FORM 3 - CERTIFICATE OF COMPLIANCE DEP 2. t/1011ti^1idate —/--�& ^ /4 the system will function as designed. 'ED FORM 5/96 No. �o -ZC7� THE COMMONWEALTH OF MASSACHUSETTS FEE /` � j&,07/Y,7,2-1 BOARD OF HEALTH G 43��Z DISPOSAL SYSTEM CONSTRUCTION PERMIT ...:.....:.... ... Permission is hereby granted to Construct ( ) Repair ) Upgrade ( icf Abandon ( ) an individual sewage disposal system at S /`_/5 h z 4ti lr �iC�00 %.rr70 $?� as described in the application for Disposal System Construction Permit No. gds G dated 7-0 — 72 Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be me, . Date %` (p — 'Fif Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON 7-