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No. 150 IA- C-I(�'��64HE COMMONWEALTH OF MASSACHUSETTS FE
BOARD OF H ESA L� T HDWA-1 —OF
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APPLICATION FOR DISPOSAL
SYSTEM CONSTRUCTIONYERMIT
UJApplication
for a Permit to Construct ( ) Repair (
1,) Upgrade
( ) Abandon ( ) El Complete System Endividual Components
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Owner's Na e
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Telephone #
Type of Building: K- k Lot Size 01
Dwelling — No. of Bedrooms Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow (min re fired) gpd Calculated design flow gpd Design flow provided gpd
Plan: Date ZP 17-C44 Number of sheets ! Revision Date
Title /
Description of Soil(s) C:::5r (Z501c,
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation /c
DESCRIPTION OF REPAIRS OR ALTERATIONS 1E,
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The undersigned agrees to i tall the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and furt r agrees not to ce the tem in roti fil a Certificate of Compliance has be iss ed by the Board of Health.
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Signed Date
Inspections Soils S �K s'�J J
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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No. 6o4+DC- I(O -Sq-5 THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH of'?,
CE TIFICATE OF COMPLIANCE
Description of Work: P4ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System;
by: O -OI W IO . V d�
at
has been installe •n accordance w ij is ns 1
plans relating to application No. 1 ' Idated -
Installer C�
),Repaired ( pgraded ( ), Aband ned ( )
itle 5) and the approved design Tans/as-built
Approved Design Flow (gpd)
Designer: �i°�f� Inspector /� !I �LZ,.,Q Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
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No. 6OC3RD(,-J -4THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygr, nted t onstruct ( V Rowir (r) Upgrale( A andon( individual sewage
disposal system at 7 as described
in the application for Disposal System Construction Permit No.
Provided: Construction shall be completed within threc-yeff of the date of this permit. 1 cal con itions mus a met.
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Date �� Board of Health t/ ��
FOR - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS& WARREN PUBLISHERS - BOSTON
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