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HomeMy WebLinkAboutApp-Permit-ComplianceNo. ©��� THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH'' -TO w R OF `'I i2_'r rv\ (f APPLICATION FOR POSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System ❑ Individual Components j 7 0/�� /YW/7 9 7% Loc Won l / Map/Parce # Installe>�am //rte�//�� ��0� Ad�dres�lL2& Telephone # Type of Building: 0 LQ Dwelling — No. of Bedrooms Other — Type of Building Other fixtures /47-6.1-01 Owner's Name Address Telephone # Cc G� Y I! i 9 !o Desjgner ame L+ O// -L-3(a Qom/ 2 2, TGelephone # 6# J Lot Size ��� bb Sq. feet 3 Garbage Grinder ( ) No. of persons Showers ( ), Cafeteria Design Flow (min. required) gpd Calculated design flow '390 gpd Design flow provided gpd Plan: Date Number of sheets Revision Date Description of Soil(s) .57-,,e IV 40lC-f -- Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr t to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ' � �� Date ✓�/ /d �6 % 'c Inspections a d FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 a NO.� THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH�5�, C RTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ©IComplete System The undersigned hereby ,, by: ' that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (),:� Abandoned ( at / 6 bt 6)1" .Z4",L- has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plan / -built plans relating to application No. -o ZL2�;L-7 dated .12 f Approved Design Flow (gpd) Installer Designer: Inspector 7� : t'" t- Date J The issuance of this certificate shad. be construed as a g ara tee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. L1 THE COMMONWEALTH OF MASSACHUSETTS FEE ;p' Li4 BOARD OF HEALTH DISPOSA SYSTEM CONSTRUCTION PERMIT Permission is hereby granted tq Cons ruct� ( Rep a' ( ) Upgrade (1(,6) Abandon ( ) an individual sewage disposal system at /��✓ 7V% 0� as described in the application for Disposal System Construction Permit No. 0-7—!:K 7 dated /.2 4 7 Provided: Construction shall be completed within_t: ar of the date of this permit. A{1 cal conditions must be met. Date 12-- r 1 Board of Health CZ%' FORM 2 - DSCP DEP APPROVED FORM 5/96 v FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS - BOSTON