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NO. ^ 1J1 'Z� ' THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
}b�
OF _4� _
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct 4/1 Repair( ) Upgrade ( ) Abandon ( ) - ❑ Complete System ❑ Individual Components
Location
MaplParcet tl
Lot #
77 I�gst__aller's Name
77 �� C',C7 4� i C!1 ,A- !vl 1L
Address
t29 r
Telephone R
Ownr's Name e
Address
Telephone #
Designer's Name
Ida C Arta, tcU "A-07[UC
7' ddicsx +
Telephone a
Type of Building: a 9 S?& tea" . , , �d S ; �� Lot Size `� Sq. feet
Dwelling — No. of Bedrooms % Garbage Grinder ( )
Other Type of Building No. of persons Showers { ), Cafeteria ( )
Other fixtures
ti
Design Flow (min. required)_ gpd Calculated design flow6 gpd Design flow provided5LL gpd
Plan: Date -SA6Number of sheets �Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS't n 1�` �; •,1 (� — 7� _y�
The undersigned ag4s to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
27
Signed Date h ., [Z
Inspections
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
NO^ �C " 1 ' {`�� THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Com onent s S to
p (} ❑ Complete System
The undersigned hereby certify thattheSewage Disposal System: Constructed ( ),Repaired(--), Upgraded( ).Abandoned( )
by: ("DA n- n rtiI A C ( A (r -� t ,
at 2 1✓1�2 f� .l ,_
has been installed in a cordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating pl' ation ^ 6 dated_ 5 Q' 1 Approved Design Flow Z {gpd)
Installer
Designer:/ i�Z_A4&1j0-L,, Inspector Date � 16 d` t
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
- \ tQ.MJl-0r-YNBOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair { ) Upgrade ( } Abandon ( ) an individual sewage
disposal system at as described
in the application for Disposal System Construction Permit No. ,y;' dated l 64
Provided: Construction shall be completed within three brpara pf the date of this permit. All local conditions must be met.
Date Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBSB WARREN' PUBLISHERS - BOSTON
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