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HomeMy WebLinkAboutApp-Permit-Compliance•No. t5Q#T) _'? 37 " THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH a45(041 © O F APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System Aindividual Components J NeJmp ma -n 'D r kv rr ren w is Nam Map/Parcel # 5 (mak 73 7 —12 4Vdre s Lot # Telephone # Instalwme:?E� fPs Designer's Name Address Telephone # Telephone # Type of Building: !� C,5 Dwelling — No. of Bedrooms Zi Other — Type of Building No. of persons Other fixtures Design Flow (min. required) Plan: Date Title Description of Soil(s) _ Soil Eva Iuator Form No Lot Size Sq. feet Garbage Grinder ( ) Showers ( ), Cafeteria ( ) gpd Calculated design flow gpd Design flow provided gpd Number of sheets Revision Date Name of Soil Evaluator Date of Evaluation The undersigned agrees .to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu er grees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ----------------------------------------------------------------------- 5S E COMMONWEALTH OF MASSACHUSETTS FEE ,`+. Q : BOARb OF HEALTH �q q/7-�� f CERTIFICATE OF COMPLIANCE N + it - Description of Work: Individual Component(s) E] Complete System �A U AA The undersigned h ;by certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by:. -Mi. at s...) 'bjt--.l t 1 1 [ j I t] t has been installed in accordance plans relating to application No U .' Installer ' i'7 , X C C Designer: The issuance of this with the oviisiokts of 310 C R 15.00 (Title 5) and the approved design plans/as-built /_ dated g � IV -/7 . Approved Design Flow 2-.>- D (gpd) Inspector / Date ©7 shall not be construed as a guarantee that the system will function as designed. ' FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 _. cc,, 6 t P� EX N leo. �W©(4.7-3155i­HE COMMONWEALTH OF MASSACHUSETTS IEE T BOARD OF HEALTH G� DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby disposal system at 13 to Construct (_ ) Repair ( ) Upgrade ( ) Abandon ( an individual sewage as described in the application for Disposal System Construction Permit No. .17 7T , dated -'I' 1 /C' —, Provided: Construction shall be completed within three years of the date of this permit. A 1 di met. st met. Date rAy i� Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS/ BOSTON