HomeMy WebLinkAboutApp-Permit-Compliance(�>UDTTL ~i ( -oo 4-1 2D
No. 8bN DG-I�; -�?o3Z THE COMMONWEALTH OF MASSACHUSETTS FEE W,06
BOARD OF HEALTH dL�3
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4"// A �l�I�_ OF
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�,A?1214CMON FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( Upgrade( ) Abandon ( ) - Complete System ❑ Individual Components
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Map/Parcel# 7F og S7AVr?
Lot # Te phone #
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staller's N me esigner's ame
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Address Address
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Telephone # -7-74--7/_>_ h 5i Telephone #
Type of Building: t_ f l Lot Size ZP, Sq. feet
Dwelling — No. of Bedrooms Is Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures ,,,, }}��
Design Flow min. required) ? 3 gpd Calculated design flow 234 gpd Design flow provided 33,6 gpd
Plan: Date �- 3o Number of sheets Z. Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator r:4 e-.- Date of Evaluation_( 2
DESCRIPTION OF REPAIRS OR ALTERATIONS /'--C' B_ j+C� 4.r (e -c'1 Cee qe o,) f C-�-r "e -C,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
t
Inspections
4iAV_�nP_ J.Pd/aiY.yiFORM I APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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No poN�C-Ib-�D3� T OMMONWEALTH OF MASSACHUSET a 4A FE .S ,00
/1�GHa/� BOARD OF HEALTH jc rC25�
CERTIFICATE OF COMPLIANCEv
Description of Work: ❑ Individual Component(s) >6 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (h', Upgraded ( ), Abandoned ( )
by: �-� � 6:C /l' 5 � U N(?
at `� ;/ , J e(t , / C.J Al -(?-
has been installed in accordance ith th rovisions of 310 CMR 15.00 (Title 5) and the approved design las/ s -built
plans relating to application No. dated V Approved Design Flow --t' -(gpd)`.
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Installer 2?fC � 0 -/ ��✓ 3 � � ?
Designer: iil E'-'` J()/1 S Inspector
The issuance of this certificate shall not be construed as a
that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. e>0Q-_iC-J(o_ OoJZPHE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Const t ( ) Repair , (,V) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at V/ �f Com/ 2.-c�✓ I�-P as described
in the application for Disposal System Construction Permit No. �fo - _ dated
Provided: Construction shall be completed within tlt ea?s ofte a e of this perp t. A11 local conditions musjj-be met.
Date �J /4 % Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBs& WARREN TM PUBLISHERS - BOSTON
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