11 Title 5 Application/Permits 2007 NU
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF /"fir ty G S•r4f0 y
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Application for a Permit to C ns'ruct ( ) Repair( . ) Upgrade (#11) Abandon (x) - Complete System �j Individual Components > di/,. fz,
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Address
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Lot 4
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Telephone
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Designer Nune
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Add'ess
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Type of Building: c 1"1 r. 7 dair It> f
Dwelling—.No,of Bedrooms ++..._ -
Other—Type of Building
Other fixtures
Lot Size Sq.feet
Garbage Grinder ( )
No.of persons" Showers ( ), Cafeteria ( )
Design Flow(ntin. required) gpd Calculated design flow gpd Design flow provided gpd
kg(t Plum. Date-i'u^e- 7, zoo 7 Number,of sheets Revision Date
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Description of Soil(s) N,
Soil Evaluator FormlNo. N4' Name of Soil Evaluator N'! Date of Evaluation /va
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DESCRIPTION OF REPAIRS-OR ALTERATIONS Sam r of ti t'c
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',sued by the Board of Health.
Signed Date
Inspeclions C wrot- 4).`ovr-rc/ o;,O rr,l i, v� 3'e,9/,c f„ 4t r^ r'rrwv r�r-,d °NA„
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FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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Description of Work:
1.64/11(
THE,,COMMIO
CERTI
Viva-
Individual C9m_paneN(s) ❑Complete System %
41L�✓� 6131-ri«-•f e..- �'�"" �;r/r
,, i the
�[wa e�1DDisposal S s[em'Constmc[ed R(:/p p�
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WEALTH OF MASSACHUSETTS
it BOARD OF HEALTH
ICATE OF COMPLIANCE
/FEES � yu al,
The un ersigned hereby certify that t Sewage s v ( ),
p iyed(,�),Uptgnraand�ed( ),Abandoned
at
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has been installed in accordan with the provi''ons 310 CMR 15.00 (Title 5) and the approved desig pla as-built
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plans relating to application Nw, O 7-0d, dated GGpc.. '; Z00-7 . Approved Design Flow
Installer /1 C I �s e:.i rL A -1;7(4/
Designer: !r<� 1T Inspector
The issuance of this certificate shall not be construed as a guar
Date
that the system wl I function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No.2 6°741
THE OF MASSACHUSETTS
�� TrhJ Ll BOARD OF HEALTH
th07
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DISPOSAL SYSTEM CONSTRUCTIO PIIRV'IIX ( JAr4 . :-�Y4
Permission is hereby granted to Construct (_ ) Repair ( ) U grade ) mild n ( ) an individual sewage
disposal system at /l t / •l a•4C- (�-1-e tit i.1? �Sc 'L .c cf t��, G' as described
in the application for Disposal System Construction Permit No. i. 4- 0 r7-' 03-- dated -1;TV- 7( »)07
Provided: Construction shall be completed within three years of the date of this peD� t m All area/`�conditi m be met.
p i 1001 Board of Health �
Date 1.4.41-e
FORM4 - DSCP DEP APPROVED FORM 5/96
FORM 12551 REV 5/961
I&W> Hoses a WARREN 19
PUBLISHERS BOSTON
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