319 Application & Permit 2006 I Pere Tesstt�WIitn7ss Payment Record ata, 02,$3
Date: t- n1 Amount: $ g, �D
Property Owner / / ' Jill
Property Address cam;A a ./ / I/
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New Construction Repair
MICHAELJ. LAVIGNE 2153
477 RIVER ROAD 53 7093 @t pe I'(
DEERFIELD,MA 01342-9758 /� > l�9/� la/ e 9 DATE
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6 E a SAVINGS BANK m,
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALo
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
:pair (K7 Gsarade ( 1 Abandon ( 7 - Q;Complete System ❑Individual Components
Type of Building: 9'
1 ?
Dwelling—No.of Bedrooms
Other—Type of Building
Other fixtures
Design Flow(min required) 4 gpd Calculated design flow opd Design flow provided Hcl vpd
Plan: Date r%'7 Iu:< Lit ls Number of sheets v (6 Revision Date tap/
Title ._�
Description of Soil(s) L_ec sv / '. .. , .� .a--e-�.- ,<ic. ov.•?. ,_„�t�.; (l -' +�t
Soil Evaluator Form No. N ) Name of Soil Evaluator nn L,.v,/1 c . �- Date of Evaluation Chi -11
DESCRIPTION OF REPAIRS OR ALTERATIONS Net r) / e/ / - t -4 -1-44 c
CaiL LAS',: e rot y /C • ! rr %er—/
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Lot Size Sq.feet
Garbage Grinder (icJ -`"-
No. of pet ms (_t Showers ( ), Cafeteria ( )
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 the Board of Health.
,-7. Signed Signed /+.•, s �� € / ), ' Date !■ ) �/-(/ J�o
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5196
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Type of Building: 9'
1 ?
Dwelling—No.of Bedrooms
Other—Type of Building
Other fixtures
Design Flow(min required) 4 gpd Calculated design flow opd Design flow provided Hcl vpd
Plan: Date r%'7 Iu:< Lit ls Number of sheets v (6 Revision Date tap/
Title ._�
Description of Soil(s) L_ec sv / '. .. , .� .a--e-�.- ,<ic. ov.•?. ,_„�t�.; (l -' +�t
Soil Evaluator Form No. N ) Name of Soil Evaluator nn L,.v,/1 c . �- Date of Evaluation Chi -11
DESCRIPTION OF REPAIRS OR ALTERATIONS Net r) / e/ / - t -4 -1-44 c
CaiL LAS',: e rot y /C • ! rr %er—/
•
Lot Size Sq.feet
Garbage Grinder (icJ -`"-
No. of pet ms (_t Showers ( ), Cafeteria ( )
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 the Board of Health.
,-7. Signed Signed /+.•, s �� € / ), ' Date !■ ) �/-(/ J�o
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5196
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
/ F-,=.:+://Fi5,4i BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: D Individual Component(s) D Complete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired( (L 1. pgraded(i-J.Abandoned
by i r%Y'i . ,L%>'I C\'., i _ I.:, rh i u• , .
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has been installed in accordq{ece with the provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built
plans relating 1p applicatiunk11). )-?4h-/. dated ,T/ U.- ; )c Approved Design Flow c) ,y 1 (gpd)
Installer - I M1 ' f �vve _a v.e (o -jy0 , f ,
I F I!C. ! /�✓t"-'11C, _ � Date i-
Dest
Designer Jr yr , a t `4. ,.,,,,:,1 "
/ 1 .;/- Ynspector , , f 5 ( - l
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The issuance of this certificate shall not be construed ed as a guarantee that the ystem will funcho s d signed .; __
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
)
No.
THE COMMONWEALTH OF MASSACHUSETTS
'i' 9 2 BOARD OF HEALTH ,'
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( Upgrade ( TT—Abandon ( ) an individual sewage
as described
disposal system at t s f h .;, <--� .'
/
in the application for Disposal System Construction Permit No /- —i .dated i ' /
Provided: Construction shall be completed within three years of the date of this permit. All local conditiansntust be met
/ Board of Health ,H,,/ a2 el/': /`"-,
Date
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 i REV 5/961 ", HAW j HOBBES WARREN"'
PUBLISHERS - BOSTON