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NO. �4c-I'7-Z29S 00,347 btu
�D THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH - '_0C
si
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System ❑ Individual Components
Type of Building: Lot Size Sq. feet
Dwelling — No. of Bedrooms Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures
Design FlowM30
requ'red) �� gpd Calculated design flow gpd Design flow provided gpd
Plan: Date r Number of sheets Revision Date
Description of Soil(s)
Soil Evaluator Form
0
No. Name of Soil Evaluator
REPAIRS OR ALTERATIONS 1'500
Date of Evaluation
N I o 5T, D3 3 d box .
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fu r agrees not to pla the syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspection , e55 L
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
-. _----- -�^7`ZZ�1e/----_--&-+ 13 CAV' ---amu � � �,/ /7 —Lrl�j��7-(�i3P��
No. �6 N T E COMMONWEALTH OF MASSACHUSE TS FEE SJ
BOARD OF HEALTH X522.1
C RTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigneereby ertify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned ( )
by: 2 � I(Q V Co (on
at �i �(�t %ov�t�� rLl1N
has been installed in accordance with tprovisions of 10 MR 15.00 (Title 5) and the approved design la as -built
plans re to application 17t.2-5 dated ' 10 �� Approved Design Flow (gpd)
Installer'' U
Designer: 00 VQ R (_% (1�, Inspector /' ` Date .2
f
The issuance of this certificate shall not be construed as a guarantee that the system will function as d signed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. 6oN�L®I%—ZZTHE COMMONWEALTH OF MASSACHUSETTS FEE �0
BOARD OF HEALTH���'2'�
r
DISPOSAL SYSTEM CONST,R�JCTION PERMIT
Permission is hereb lyra t d to Construct ( ) a' ( ) Upgrade X) Abandon ( ) an individual sewage
disposal system at 1 "b0 &( y ij I as described
in the application for Disposal System Construction Permit No. �' �`- dated f _11-r�''-/ 7
Provided: Construction shallbecompleted within rs of the date of this permit. %local cond't'o must be met.
Date -/7 Board of Healthy
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON