HomeMy WebLinkAboutApp-Permit-ComplianceNo. 302 22
OC-1�"ZZ�✓I'HE COMMON A MASSACHUSETTS FEE Sy��o
BOARD OF HEALTH (0 go
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APPLIMION OR DISPOSAL 7)Abandon
EM Cro..'ple'te
RUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) --System ❑ Individual Components
No. 00+41)c,-Ig.22�7-4 COMMONW ALTH OF MASSACHUSETTS FEE pp�n557, Qo
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE o
Description of Work: ❑ Individual Component(s) omplete System 1�.5
The undersigned hereby
by:
aty F—r- �_ J
has been installed in
plans relating to ayxl
Installer
T
that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded , bandoned ( )
No.
Designer:I U kA.41 1
The issuance of this certificate shall not be onsl
FORM 3 - CERTIFICATE OF COMPLIANCE
44"
of 310 CM1 5.00 (Title 5) and the approved desi n p as -built
Approved Design Flow (gpd)
pector^��� p-Ctjl Date /
d as a guarantee that the system will function as designed.
DEP APPROVED FORM 5/96
p� G DD
No. VQ-4DC-�( s-Zz+ 4HEMONWEALTH OF MASSACHUSETTS FEE CAA
\77molAt—BOARD �+�'"" OF HEALTH 6g53
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is he eby gra t d to Cons uct ( ) epair ( ) Upgrade .(/f Abandon ( ) an individual sewage
disposal system at Tc ( G as described
in the application for Disposal System Construction Permit No. ( dated 42— --/ —/, 0 -
Provided: Construction shall be completed within three years of the date of this permit. r; P onditions must be met.
Date 2- `"� ' �4 Board of Health
FORM 2 - DSCP DEP APPROVED FORM S/96
FORM1255 V 5/96) H& HOBBSB WARREN TM PUBLISHERS - BOSTON
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(Locati-
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O s ame
Map/Parcel #
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V Lot # ,`,
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Desistggi �1ame
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Telephone #
Telephone #
Type of Building: �C I
Dwelling — No. of Bedrooms
Other — Type of Building No. of persons
Other fixtures
Lot Size d pie& $ feet
Garbage Grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. re uir d) gpd Calculated design flow
Plan: Date o I5 Number of sheets
Title
gpd Design flow provided pd
Revision Date
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator
D C I ION OF REPAIRS OR ALT RATIONS / �-IGU
U?CAI og-b ev
Date oft /Evaluat_�i�on
/V �d S r /Y � ��(
Theundersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and f he agrees not to a the sys in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 3 L'
Inspections 49,C11O
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM
5/96
No. 00+41)c,-Ig.22�7-4 COMMONW ALTH OF MASSACHUSETTS FEE pp�n557, Qo
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE o
Description of Work: ❑ Individual Component(s) omplete System 1�.5
The undersigned hereby
by:
aty F—r- �_ J
has been installed in
plans relating to ayxl
Installer
T
that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded , bandoned ( )
No.
Designer:I U kA.41 1
The issuance of this certificate shall not be onsl
FORM 3 - CERTIFICATE OF COMPLIANCE
44"
of 310 CM1 5.00 (Title 5) and the approved desi n p as -built
Approved Design Flow (gpd)
pector^��� p-Ctjl Date /
d as a guarantee that the system will function as designed.
DEP APPROVED FORM 5/96
p� G DD
No. VQ-4DC-�( s-Zz+ 4HEMONWEALTH OF MASSACHUSETTS FEE CAA
\77molAt—BOARD �+�'"" OF HEALTH 6g53
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is he eby gra t d to Cons uct ( ) epair ( ) Upgrade .(/f Abandon ( ) an individual sewage
disposal system at Tc ( G as described
in the application for Disposal System Construction Permit No. ( dated 42— --/ —/, 0 -
Provided: Construction shall be completed within three years of the date of this permit. r; P onditions must be met.
Date 2- `"� ' �4 Board of Health
FORM 2 - DSCP DEP APPROVED FORM S/96
FORM1255 V 5/96) H& HOBBSB WARREN TM PUBLISHERS - BOSTON
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1A C,I rl , � r