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No. "'22-yT THE COMMONWEALTH OF MASSACHUSETTS FEE $$5.00
7
,,-,BOARD
BOAR /D- OF HEALTH c 217(
O F (0 PCJJR'
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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MAP 14 nLocation-1P pR.La L-7,4
Map/Parcel #
Lot #
fla C Los - 14c"
Installer's Name "-�
Gp,cwr Lilawfla 90 A,
50' _34 fJ 7 eeC'
Telephone #
C1} 1Z
Own r' Name
'-11 Ca.�S��rt_rr. n, 3>,L4 amu.
Address MON
A 1� 4�
Telephone # t �y1 V
J>ot.rlic�rt frtjl r- •may
! Desi�ner�s jVame a, A
sari - 361-4 � 41
Telephone #
Type of Building: 1 f --A- MwT 143tDewk+� Lot Size 10.*WV,1-q.
S feet
Dwelling — No. of Bedrooms .'fir Garbage Grinder (-+, f.W Wig'
Other — Type of Building No. of persons 1-0 Showers (Z1, Cafeteria (�--•
Other fixtures Z IA W Z LAIC) t 14TI-A J Qv D$T A -) Id' . Z f Pt G � Ir
Design Flow (min. required) -550 gpd Calculated design flow gpd Design flow provided ,S I- gpd
Plan: Date!Z 1i 6L 7-0 L C Number of sheets d Revision Date
Title _ 15
Description of Soil(s) L-. L -CO 64 11 \i.D t V m J� W ID
Soil Evaluator Form No. 1'3 R '7 J Name of Soil Evaluator MOMS f 4,01Xl Date of
DESCRIPTION OF REPAIRS OR ALTERATIONS�'�?Sa'!*1G
aJSd11oK FA
1.6
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 �u-w..� r✓>v� V/Date �/�11 1-A
Inspections -50 ORS OP ft4gi, t ;t-1 3 134t&-tw G
If FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No.Y*NOC-��1'2�y�! THE COMMONWEALTH OF MASSACHUSETTS FEE cjk-;� 2?%1
`fA9r+4�-,%0 BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: E] Individual Component(s) WE (U., plete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned
by: 1lUeG-y " CAILUS 11,)c
at -ZO VXEtA LQ CAIC- YAk`T:k
has been installed in accordance with the pr visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. /.7 ` .� " %� Approved Design Flow -$45 ' gpd)
Installer
Designer. I)a a)h1C J?L et ICsJ. IQ (-(rWp(r Inspector
The issuance of this certificate shall not be construed as a gdarantee that the system will function as designed.
DEP APPROVED FORM 5/96
FORM 3 - CERTIFICATE OF COMPLIANCE
t� C10 I LDS
No. �%�t-"�� �2'�ll HE COMMONWEALTH OF MASSACHUSETTS
/7 -"&rP,.Q j'k' BOARD OF HEALTH
FEE QV
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( N Upgrade ( ) Abandon an individual sewage
disposal system at 70 )-1 t:w)bz L-1< t S 0 - fzy% 0aTVl Ma as described
in the application for Disposal System Construction Permit No. / :.�-�L , dated & zLZ --
Provided: Construction shall be completed withir,L ree s o the date of this permit Al GZF
ust be met.
Date 1— 2, —! � Board of Health
FORM 2 - DSCP DEPAPPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS - BOSTON