526 Septic Application Permit & Compliance 2004 No. 7%Dy-3 y
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THE COMMONWEALTH OF MASSACHUSETTS RE
//� J BOARD �OIF/ HEALTH leg.
l _I4y OF l VOr+yl9vr,G1Dh /
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Appl lca Lion for a Permit to Construct t Lf nepair ( ) Upgrade ( ) Abandon ( ) - mplete System
Individual corn onems
Flo L.+ Ad'arc.,{ 1. SzOF(rester Rood
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no Florence e./, F/;ehrq /4,4 0106
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C86-6396
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`' PO. Box 226 Nor A acid MA olobb
24-7-54b4
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"ateCaA1Nte:Mme ,e,,51,467407it
Address
Tmopeu¢>
rolepnuoc i
Type of Building: S.yL w);(7, qA Yw
Dwelling—No.of Bedrooms 3
Lot Size 10.6 04 Ares Sq.feet
Garbage Grinder (✓)".
Other—Type of Building No. of persons Showers ( ). Cafeteria ( )
Other fixtures
Design Flow(min. required) 4911 gpd Calculated design flow 4YS apt) Design flow provided Sz I gpd
Plan: Date Amy. 27 go o+ N iber of sheets / Revision Date
title
Description of Soil(s) �sT
Soil Evaluator Form No. Name of Soil Evaluator /9, /At do rron Date of Evaluation -4726704-
DESCRIPTION OF REPAIRS OR ALIERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
� ff��jjTITLE 5 and • agrees not .[place the system in operation until a Certificate of Compliance hasp been issued by the Board ar/ ,..
{'Signed 'L/ e_ - a - ,>� Date (�Z1/6 /Ate tam
//�T Inspections + ;
sIAI, 4
FORM 1 - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
_T
No.;en' t/—_
Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS
I
�Vrr +nm .,, pTbr. BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
❑ Individual Components) [ omplete System
Fir /(?)
:'6(4,;
The on..- .ned hereby certify that the Sc Disposal System:Con s✓ eed( s epaired( ),Upgr ed( .Abandon( ( )
bv: � � �' L�Sa a /. i . rat..nsilit —�i .�... "
at _ ��i ss%JI -
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has been installed in accordance with the rovissions o 310 CMR 15.00 (Title 5) and the approved design p ant/as-hail[
plans relating to application No dated . Approved Design Flow design
(gpd)
Installer // °ehbier _...--
Designer: rY14)54 f hOlesii,) Inspector SaDate_e9ok2/4.-5
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:d=
THE COMMONWEALTH OF MASSACHUSETTS
∎Jc. 3-Lc. :-i-v:- BOARD OF HEALTH
DISPOSAL SYSTEM/CONSTRUCTION PERMIT
Permission is herebypa,pted to C?nstruct (� Repair ) Upgrade ( ,) Abandon ( ) an i cividual sewage
disposal system at -!' '�'" / .r�d > `. . G `7 _ . . :v as described
in the application for Disposal System Construction Permit No. 'D4 — IS c( ,dated L J ,.;/rf 245 It
Provided: Con/s)ruction shall he completed within three years of the date of this permit.All local conditions must he met.
Date L, Y/�T—��.,_� -I a. Board of Health � . ..�=t,i.'1'l" -C.(��
ERNEST J. MAT'IIE0. R.B., MS., C.H.O.
DIRECTOR OF HEALTH
FORM 2 - DSCP
DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) <H/W J HoBAS&WARREN,u
PUBLISHERS- BOSTON