538 Application & Permit 2001 THE COMMONWEALTH OF MASSACHUSETTS Fr
BOARD OF HEALTH
TOW,U of QON- rim x
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit to Construct (k) Repair ( ) Upgrade I ) Abandon ( 1 - Complete S>stein ❑Individual Components
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Type ling—No. S( �. mI
I Ij Lot Size Sq. feet
Dwelling—No.of Be ooms 3 Garbage Grinder ( )
Other—Type of Building No.of persons to Showers ( ). Cafeteria ( )
Other fixtures 7 Design Flow(min.required) licRI- epd Calculated design Flow epd Design flow provided51 7 gpd
Plan: Date 6 )Q'O( • Number of sheets Revision Date
Title
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Description of Soil(s) S.Q.I �l� Res
Soil Evaluator Form No. Name of Soil Evaluator 1 Da
of Evaloationmc {-0)
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigns
TITLE 5 and further
4-Signed
Inspections
rees to install the above described Individual Sewage Disposal System in accordance with the provisions of
not . place a stem in operation until a Certificate of Compliance has befn issued by the Board of Health.
Dale
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FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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No.
THE COMMONWEALT OF MASSACHUSETTS
BOARD OF HEALTH
Foe /�
CERTIFI ATE OF COMPLIANCE
Description of Work: ❑ Individual Componentls) 'Complete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired( ).Upgraded( ).Abandoned( )
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by - L ,.
at 53T S /Ve 5 . et ,-
has been installed in actor nee with the provisions of 310 CMR 15.00 (Title 5) and the approved design plaps/as-built
plans relating to application No
�I at) dated % 3/' O / . Approved Design Flow ��l (gpd)
Installer . u (!' '�C� _ (/y �j /
Designer: rid r/ f'' f/ C"r(? V Inspector -I G%�u�(/JCv.Vate �' ��,.�
Theissuance 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
Via (%'." _ G' THE COMMONWEALTH OF MASSACHUSETTS Fefi
4///(1 /('i6ij" i T ^BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby r nted to Construct epair ( j) Upgrade ( ) Abandon ( ) an individual sewage
t c as described
disposal system at I--/- Cc, �UF - /
in the application for Disposal System('onstruction Permit No. /' / - J/ ,dated
Provided: Copstructionshall he completed within three years of the date of this permirsAilTocal conditions rquyt V met.
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Date t g-r/ i-� / �(t / Board of Health /-"' ` c<
FORM 2 - DSCP / DEP APPROVED FORM 5/96
FORM 12551REV 5/961
(-HEW J Hoe„,WARREN rm
PUBLISHERS 50STON