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No. D`� THE COMMONWEALTH OF MASSACHUSETTS FEE 5V e
f�Q� BOARD OF HEALTH D(a
OF A4 vrc tom/ G J► C
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade X) Abandon ( ) - ❑ Complete System ❑ Individual Components
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Locatign `
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Telephone #
Type of Building: I" F_
Dwelling — No. of Bedrooms
Other — Type of Building _
Other fixtures
Design Flow (min
Plan: Date a
Title
Description of Soil(s) __
Soil Evaluator Form No.
o. of persons
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Owner's Name
Address
Telephone # j.OZ—
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Telepho
Lot Size 1360 Sq. feet
Garbage Grinder-( )
Showers ( ), Cafeteria
gpd Calculated design flowgpd Designpr vided � gpd
Number of sheets Revision Date --- ��V /
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
0417, Date of
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 Date
Date 17 d
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
- - - - - --- - ------ - -- -- ---
No. - THE COMMONWEALTH OF MASSACHUSETTS FEE 7
BOARD OF HEALTH � 1 ,
ERTIFICATE OF COMPLIANCE I
Description of Work: ❑ Individual Component(s) EXomplete System
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The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded ( ), Abandoned ( )
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has been installed in accord ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. 0/- /1�� dated S 7` U / . Approved Design Flow (gpd)
Installer n , (¢1
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Designer: ! .u/I/ �/�`�f �( / Inspector ate
The issuance of this certificate shall not be construed as a guarantee at the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. el�! 49Z THE COMMONWEALTH OF MASSACHUSETTS FEEf CP
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BOARD OF HEALTH toe,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( Repair (V/) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at as described
in the application for Disposal System Construction Permit No. ��G dated
Provided: Construction shall be completed within the the date of this permit. local conditions must be me
Date ' 7 1��/ Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS -/BOSTON
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