HomeMy WebLinkAboutApp-Permit-Compliance�,a Pc- 18-10 (3,TM-tct— C�o3G2(�
NO. �HE COMMONWEALTH OF MASSACHUSETTS FEE5v`�0
BOARD OF HEALTH 4
T 'Q'vJ N OF %ARM OU TH
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) llpgntde (�) Abandon ( ) - Wcomplete System ❑9ndividual Components
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M t K 1E_ Lot NS1 W E9IJ
Installer's Name
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.16, t'LMlWCM .'M1, N bt MC'I Y\ A
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Telephone N
Type of Building: & M 511 TAM I L`J Lot Size 1 EiQQZ Sq. feet
Dwelling -- No. of Bedrooms (b Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow (min. required) 6 bV gpd Calculated design flow .7' r1 gpd Design flow provided 7 HIi gpd
Plan: Date ] I ' 30' 1 Number of sheets i Revision Date N A
Title S QATA G `( M DESIGN
Description of �' O �� '_'S. IT- i r M.shh m -11 ` M.. SA N D
Soil Evaluator or N e f Soil Evaluator L- LEI ► E-RI RL Date of Evaluation
DESCRIPTION Ly TIONS RULME CM5'P0_l VITh / 50n SIT,
The undersigned a ' _ hll bed Erid'mdual Sewage Disposal System in accordance with the provisions of
g G � eseri ..
TBTLE S and further „ g in operoNon Nt a Certificate of Compliance has Bss by the Board of Health.
Signed Date i g I?,
Ins ections
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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NO.—� -' THE COMMONWEALTH OF MASSACHUSET S / FEE55.00
YL\RMDUTK BOARD OF HEALTHA 't6if f
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) KJ Complete System
The undersigned hereby certify that the Sewage Disposal System, Constructed ( `), Repaired ( ), Upgraded (4, Abandoned ( )
by: �Z S W� N Ell Q(C A V A7 NCr--
at
has been installed in accordance w th provisions 9 310 C R ..00 (Title 5) and the approved design plans/as-built plans relating to application No. dated ! -> / Approved Design Flow (gpd)
Installer
Designer: Inspector !.W Date,��
The issuance of this certificate shall not be construed as guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
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P (A AD IC 18-1 oft_
No, _ THE COMMONWEALTH OF MASSACHUSETTS FEE
S yAML1V T�\
I� BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby, r nted to Construct (1l} Repair ( ) Upgrade (V) Abandon ( ) an individual sewage
disposal system at I Plael N A V E as described
in°the application for Disposal System Construction Permit No —,dated
Provided: Construction shall be completed within 4CT'Arars of the date of this permit. Al 1 condi'7 st be met.
Date ^� l� r rBoard of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H6eW HOBBS8 WARREN PUBLISHERS - BOSTON