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No. 6o4DC418 3'��OMMONWEALTH OF MASSACHUSETTS FEE
BOARD F HEALTH Cq 35
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APPLICATION FOR DISPOSAL S-V M CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair,( ) Upgrade (. Abandon ( ) - ❑ Complete System Individual Components
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Map/Parcel #
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Telephone #
Type of Building:
Dwelling — No. of Bedrooms
Other — Type of Building
Other fixtures
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12
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S ( LCI)V r Telephone #
Designer' Name
Address
Telephone #
Lot Size Sq. feet
Garbage Grinder ( )
No. of persons Showers ( ), Cafeteria
Design Flow (min. required) gpd Calculated design flow gpd Design flow provided �pd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator o 71 Aate of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS K XG d b® , Q CK-
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE S and furth r agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 23 `I
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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No C)+� v���' 31 5�HE COMMONWEALTH OF MA�HU E T� I EE
BOARD OF HEALTH
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CERTIFICATE OF COMPLIANCF,,2,i�t ����
Description of Work: individual Component(s) Q Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
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has been installed in accord nce w' the provisions of 310 CMR 00 (Title 5) and the approved design plan as -built
plans relati�o application No. Y�dated �i Approved Design Flow (gpd)
Installer
Designer: () n C. - QN I (IQ (f".1-104sp
The issuance of this certificate shall not be construed
FORM 3 - CERTIFICATE OF COMPLIANCE
that the system will function as designed.
DEP APPROVED FORM 5/96
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No. HE C MMONWEALTH OF MASSACHUSETTS FEE QV
is .Z 1( U BOARD OF HEALTH C3Z�
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gra t d to Construct ( Repair ( } Upgrade +- Hnandon ( ) an individual sewage
disposal system at 12 i i5�% er l / q as described
in the application for Disposal System Construction Permit No. / l dated
Provided: Constructionn shall b completed within tj ,ass of the date of this permit. 1 1 conditions m met.
Date (0 % Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON