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No. 130WjiC--Ib--863fo THE COMMONWEALTH OF MASSACHUSETTS FEE
/6 —�;7 BOARD
9 OF HEALTH C 361
laI)!� OF `farM0Q41 %
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair (t/j Upgrade ( ) Abandon ( ) - ❑ Complete System ndividual Components
IG AnC0eV%5Cff (2 r_C C_
Location
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Map/Parcel #
f3 a EXca.Lv l O -i
Installer's Name
Iy 3oaSCrru LIN) ForCsi-AO' C.
ddress
S019. 477. 06S3
Telephone #
Owner's ame
1G fCc.r,cornsc Cir���
Address
Telephone #
�D $C f'n7 V l r on rrlcn�a�.
Designer's Name
Address
S08. 4933 -Z1e7T7
Telephone #
Type of Building:Lot Size Sq. feet
Dwelling — No. of Bedrooms %1 / a f j�fl�, Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures11_11_PA
1 I V
Design Flow (min. required) 42119gpd Calculated design flow gpd Design flow providedgpd
Plan: Date Number of sheets Revision Date
Title '3-S.16
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator
OF REPAIRS OR
of Evaluation
L� Cr zr Sim
.. / 7 r,--4 5 r
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not toplacethe system in operation until a Certificate of Compliance has been issued by the Board of Health.
he^
Signed 1l2c , 7'CLQ�JI� Date QX�W'7. �.
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. WDC -I( --$93(o THE COMMONWEALTH OF MASSACHUSEAS
,�--j 7 BOARD OF HEALTH-"-
CERTIFICATE OF COMPLIANCE
Description of Work: [Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (✓j, Upgraded ( ), Abandoned ( )
by: ��3C�Va�►o�
at It, r5C000M5c7'7 L. t r -c;
has been installed in accordance with the
plans relating to application No. /61
Installer G
of 310 CMR 15.00 (Title 5) and the approved design `plans/as-built S
- i'( Approved Design Flow 7 � (gpd)
M
Designer:rJ U ► r-0 r1 m c -nix 1 Inspector
The issuance of this certificate shall not be construed as a
FORM 3 - CERTIFICATE OF COMPLIANCE
gy(raniee that the system will function as designed.
DEP APPROVED FORM 5/96
6 i-& excUPt-nov\J
No. DC—I(,,-9936 THE COMMONWEALTH OF MASSACHUSETTS FEE
/6, -� % cr)la r-r-iou 7k BOARD OF HEALTH `I
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair (✓) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at 1 1,� c,t conn S ori e i'- c 1 C as described
in the application for Disposal System Construction Permit No. /,"6 - % dated
Provided: Construction shall be completed within rhzaolv_arsof the to of this permit. All local conditions must be met.
Date Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON