357 Application & Permit 2006 No. /.. G�" THE COMMONWEALTH OF MASSACHUSETTS
--+BOARD OF HEALTH
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit to Construct ( 1 Repair ( Upgrade ( ) Abandon ( , - EeCompleie System E Individual components
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Dwelling—No.of Bedrooms
Other—Type of Building
Other fixtures
No.of persons
Lot Size
Garbage Grinder ( )
Shower ( ). Cafeteria ( 1
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d Calculated design Clow 4)% gpd Design flow provided -2,I i 25 opd
Design Flow (min. required) -!, i gpd n g
Plan: Date It/17 Itriq Number of sheets / Revision Date
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Description of Sods) ✓ =-^'
Soil Evaluator Form No_ Name of Soil Evaluator / i', f p_fr- Date of Evaluation //2 it;
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DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by th/Boerlpf�Health.
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Sinned ,,-r---e-u 3Y. -1-t- Date
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS
Ayl:,-3F,r,:, ,fen, BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) [✓]Complete System
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The undersigned hereby certify that the Sewage Disposal System:Constructed( ). Repaired( ).Upgraded( ).Abandoned
by:
at - 7
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No71)06.."%4,dated . Approved Design Flow (gpd)
Installer
Designer: Inspector Date
The issuance bf 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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( Upgrade ( . ) Abandon ( ) an individual sewage
disposal system at (7 k i �w,i�� ,, . .1 — - . �.<,. - °as�rso d
in the application for Disposal System Construction Permit No. v ,"r,— i�
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must he met.
Date %"i.r-1✓ Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 12551 REV 5/961 (Ii&W HOBBS&WARREN T"
PUBLISHERS-BOSTON