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Lot 5 Septic Application & Permit • No. /2 THE COMMONWEALTH OF MASSACHUSETTS Prr 7-C BOARD OF HEALTH 0(A k ) OF 4 Uo r+ c to t&) APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT ‘ppllcirmi ibr a r,rmn m t bnarrict Repair 1 t per:ul_ /Crf uc* BO`d_ -coiresiiro,5 (auk A P:mdon I X( emplar S■• ean _Indi,!Judi('onipaeni. Je/ Ezr fL en(' /3ox31 A)„r+l ert7cr.), . . I 55y - 9G 9_�(.) crQLAD E/V Ji roraQ/.JLc _t/ e_ /d Spru, c-ems Pci oxS1g rPe „C. fill r} o/0,3 Type of Building-.IA 'c ��.0 nxi 1,3 Dwelling—No.of Bedroc is ri �J Other-T pe of Building Other fixtures Design Flute(min. require I) CZ epd Calculated design flow gpd Design flow p rocidcA 4o_gpd Plan: Date )c- 1 3' 98 Number f sheets / Recision Date Title Sew44F his oSO! S. Sten, - -.7ulcheC — Description of Soil(s) SG-r_ r i -11 4 I i2..." 170 r- SA I iot Size Sq.feet (^� Garbage Grinder f No. of person Showers ( I. Cafeteria Soil Evaluator Form No. Name of Soil •v'tluvor Th .CCU}5 AJQ Date of Evaluation G %9 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 pl•ce the system in operation until a Certificate of Compliance has been issued by the Board of Health. e` I� � Date IZ\��I�K Signed Inspection J FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 a No. ti THE COMMONWEALTH OF MASSACHUSETTS et-Inl7Lr A, BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: [] Individual Componengs) The undersigned hereby ccrtil that the S aze Disposal System S. by: / �' AOL.! CPI �127�#S-/ AV1C lI /.( r at /- u. .r I NC c /<r-� JW �., , has been installed in accordance ys ith the provisions of 310 CMR 1 5.011 (Title 5) and the appror d design plan plans relating to application No. y- 'J _ dated 4--"' / °�'j Approved Design Flo y W JCmnplete System Irncted( . Repaired t ).t p I ed( ).Abandoned( ) is-h uilt (upd) Installer - - - - e ,� / Designer /C. '^ Inspector �t�4- / ' --- Date 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 Q a� 1 ' / 'I_:d_BOARD OF HEALTH DISPOSAL SYSTtM CONSTRUCTION PERMIT / Permission is hereby _granted Vo Construct 1,..A',/Repair ( ) 1 L p rade disposal system at L✓:r 7/!E. _ in the application for Disposal System Construction Permit No. y Abandon an individual scavage as described dated /7`�'c Provided: C1812 2611 shall be compled within three years of the date of this permit AU lidtal conditions tile met. Date / /7/ 2 Hoard of Health Y/f< dJ ul ___ A FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 1REV 5/961 IMti I Hoses d WARREN ° PUBLISHERS BOSTON