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No. 450 THE COM ON EALTH OF MASSACHUSETTS FEE
- BOARD OF HEALTH
APPLICATION FOR DISPOSA SYSTEM CONSTRUCTION PERMIT
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Application for a Permit to Construct ( ) Kepair ( ) upgrade W ) Aoanaon ( ) - Lj t_ompiete System Li inuivtuuat wutpuuctrts
Location
1 t '-I' L Z
` Mt / arcel #
Lot #
Installer's'N e
� rz.� , 1.Jam=n,..► Mtn, So ,��l�.n� , Y�
Address
So 8-318.25�6
Telephone #
Owner's Name
Address
Telephone,#
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Designer's Name
Address
Telephone #
Type of Building: KS Lot Size IS , G Co jFSq. feet
Dwelling — No. of Bedrooms `{' Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow (min. required) `� o gpd Calculated design flow gpd Desi n ow provided `i ` 3 gpd
Plan: Date t Z't`t ��`l Number of sheets I Revision Date A
Title -T,Ti-g- S
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator 5�-�-�. Date of Evaluation 1 Z--0-
DESCRIPTION OF REPAIRS OR ALTERATIONS
y p ry
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further a e of to ace the sys in until a Certificate of Compliance has been issued by the Board of Health.
Signed Date /2
Inspections
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. %
Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS FEE
•�G,AOARD OF HEALTH
CE TIFICATE OF COMPLIANCE
❑ Individual Component(s) omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,<, Abandoned ( )
at /e`CJ
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved desT/as-built
CD ,he
plans relating to application No. , dated /— CJ b ign . Approved Design Flow ans (gpd)
Installer "—E5 00
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Designer: ifLr//Ll �►°%f �E � lrr/'/lAinspector V,,Iw\ Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. THE COMMONWEALTH OF MASSACHUSETTS FEE r
✓d� BOARD OF HEALTHlta
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade (/--Abandon ( ) an individual sewage
-disposal system at / dTJ�7 �- as described
in.the application for Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All al conditionsp. �usstt be met
Date ,- � ..��' �y Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS - BOSTON�
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