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HomeMy WebLinkAboutApp-Permit-Compliancei XtAUVP Ok THE COMMONWEALTH OF MASSACHUSETTS FEE ���cl �� `�S�Cs��` T BOARD O F HEALTH C6 l L. SOF Yp o uT 4 viii H l�`� ✓ /�Git APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT �2en�u Application for a Permit to Construct (Repair ( ) Upgrade ( ) Abandon ( ) - [Complete System ❑ Individual Components "75 Summcn = T� ` -v iw Rtz- A m to �cg► X23 04-.b 2 3 Map/Parcel � //,2 t rrr 7 ' CIZL Install Name A l ' Address Telephone # / caner' ame Z14 Q Lp htior►l� mss RWM _ lMA dress P lephone # jr�,fi,�ryl��� - Address C Telephone # Type of Building. 1 li�M' 14 RA!9 rrDtWX_6 Dwelling — No. of Bedrooms Other — Type of Building No. of persons Other fixtures Lot Size3`1,3 `ia Sq. feet Garbage Grinder f--j----� Showers ( ), Cafeteria ( ) Design Flow (min. required) gpd Calculated design flow gpd Design flow provided 56E gpd Plan: Date 22 94 Number of sheets 4 Revision Date Description of Soil(s) LA ZVUVL_ VIJ-VV Z51—+ Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned TITLE 5 and further 0 Signed Q 1(ji':t Yw 1X --0y -vD Date of Evaluation 1-7 mnIL ddscribed Individual Sewage Disposal System in accordance with the provisions of in operation until a Certificate of Compliance has been issued by the Board of Health. Date Z`1'I'J" 1-140"' /51 ri vago 4V FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. 0S-1/ THE COMMON WE LTH OF MASSACHUSETTS FEED lJ ` W;% BOARD OF HEALTHC4 CERTIFICATE OF CO PLIANCE Description of Work: E] Individual Components)Complet System The undersigned hereby certify that the Sewage Disposal System; Constructed (,Repaired ( ), Upgraded ( ), Abandoned ( ) by at z 7:;;P . �y/c i has been installed in accordance with theprovisions of 310 CMR 15.00 (Title 5) and the approved design 1 /as -built plans relating,, to application No.,0 " / dated / .� % ^ � Approved Design Flow (gpd) Installer 4xt'5&✓� 7 C/-11 C b ,S ,, Designer: /7 A� InspectorIC_.4 U�Date 7— 0/ The issuance of this certificate shall not be construed as d g%uarante that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. / THE COMMONWEALTH OF MASSACHUSETTS FEE YM BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct (�Y'Re atr ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at 7� SG��'l/r72 as described in the application for Disposal System Construction Permit No. �O }� , , dated 1-2 (D 0<4 S -. Provided: Construction shall be completed within -Of the date of this permit. l local,condi�must 7 '- Date /2 — C/ CJ Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS - BOSTON