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No. 7 v-3 THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTHG��I�7�
O F ! /Z
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair (x) Upgrade ( ) Abandon ( ) - XComplete System ❑ Individual Components
Location
Zf o - ZY
Map/Parcel #
Owner's Name
Address
L # Telephone #
Installer's Name �j�iyyQDisigner's��`
JVs' �9 7, L CJ% Ad@dr'ess q�/
Telephone # Telephone # i
Type of Building: /C 6�-_.5 /d5? �/Y7�� �P G
Dwelling — No. of Bedrooms 3
Other — Type of Building No. of persons
Other fixtures
Lot Size g! ,3'T%% sq. feet
Garbage Grinder
Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow gpd Design flow provided ,_/gpd
Plan: Date 2 Number of sheets B Revision Date
Title .42 " / Oti E' E D/ $�.00..a�C 4t 6r�r.—
Description of Soil(s) E 0"z—
Soil
"zSoil Evaluator Form No. Name of Soil Evaluator G. Jo!�/EGO Date of Evaluation 2 -
DESCRIPTION
DESCRIPTION OF REPAIRS OR ALTERATIONS TJ15 iQ(( 15-m jai &&f!" r o ,!'K b- Esc
3,�ltaaora�; :1 figs �n4 e
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 I � � Date Z- Z Z- ZoUs
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
Ly ;y _
No. 73 THE COMMONWEALTH OF MASSACHUSETTS FEE Pj
YAW'9G,` L' // BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) 2 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired k), Upgraded ( ), Abandoned ( )
by: e4 "Jr C LIC
at /I C Qnd ld L934 (' 14"FS
has been installed in accordance with therovisions of
plans relating to application No. �3 dated
CMR 15.00 (Title 5) and the approved design plans/as-built
Approved Design Flow (gpd)
Installer
Designer: /SSG Cuero. Inspector:. -0, `Va 1- Date�!i
The issuance of this certificate shall not be construed as a guarantee that t4 system ril function as de gned
_FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. DT%3 THE COMMONWEALTH OF MASSACHUSETTS FEE t/C1
BOARD OF HEALTH ��:1�.:"Cf t
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to, .Construct ( ) Repair/,( ) Upgrade O Abandon ( ) an individual sewage
disposal system at'� ✓,�! ;�`���i.rt%%�'i9� '` ' as described
in the application for Disposal System Construction Permit No. e)'; —7J dated
Provided: Construction shall be completed within t�ars'off the date of this permit:1 lqc fico/nditions mu t be met.
Date �% ,�' `.�Y Board of HealthV�
FORM 2 - DSCP DEP APPROVED FORM 5/96 ✓'
FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON