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589 Septic Application Permit & Compliance 2003 /03 No.No. THE COMMONWEALTH OF MASSACHUSETTS . ' BOARD OF HEALTH ei 4-y OF APPLICATION FOR DISPOSAL SYSTEM C go Fr.r'. `t, -- pplication for a Permit to Construct - ❑Complete System ❑Individual Components St9 P�arenzt / on /c--;v.^ {JrrS re ii ireatu'a � fy9 Florence irsCrrs%tonne._ M/}orob z MatilVnrtol 4 Address sal- 1028 p��IF 2 1 ,en'e'noneeF f����'1'Owt.s F_n vird-smen{p/ cons./4,k, P,0mnalleavam: 3 '. wy 9 1 . Box 216 eq 1-{n� 0/44 mat. D 73 e m,.". 247 -r44,4-x.;'464- Telephone it Ttlaphoner Type of Building: .5-in,/e Fg..; ly bwe-I GI, Dwelling—No.of Bedrooms 4 Other—Type of Building Lot Size Sq.feet Garbage Grinder (NO) Showers ( ), Cafeteria ( ) No of persons Other fixtures Design Flow(min.required) 440 gpd Calculated design flow 470 gpd Design flow provided 470 gpd Plan: Date 19. '1003 Number of sheets I Revision Date Title <its nye_ 17:s Posat�1cAa.- 1�(daY Description of Soil(s) S t t evai..44ar Rorv,. ) Soil Evaluator Form No. Name of Soil Evaluator M .�v.^Pso.. Date of Evaluation 6 /303 DESCRIPTION OF REPAIRS OR ALTERATIONS P. Me.Ev ini n /(epince ev+Ilt sys tens- &le✓ 1500 yesf/en Sapid -fate.k.. j /2 ix 4C.c 1.5'fuller/ The undersigned agree to install the above described Individual Sewage Disposal System in accord . prov signs of TITLE 5 and rther agrees^,(°'place the system in operefian until a Certificate of Compliance has bee �.>.a..`' of Health. *Signed V I & Date`a�0 � � Inspections 'Fi% ..a, 4 al \WES FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. 971-(T3 Description of Work: THE COMMONWEALTH OF MASSACHUSETTS N0/4to spivh BOARD OF HEALTH CERTIFICATE OF COMPLIANCE ❑ Individual Component(s) XComplete System AP FEE /6.-/ The undersigned hereby certify/t�ha It/he Sewage Disposal System:Constructed( ).Repaired( ),Upgraded( ),Abandoned ( ) by: fv- (/I;:.fi, C lc`c- K "P'vIN lJ4 ' "i t'Ci1/ !/ hH 4; has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 2- - C 3 dated (i - D .. - 6 3 . Approved Design Flow [/ 9/, (gpd) Installer 12-6) i v)/i 8 ,2 / Designer: /f'/i�¢ b Tl4/'t 1/)".r./5-4/ Inspector -, ./ �� �r1-on 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 f-(g„c_FEE ->C Not Piw”—..p4r t BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair..(j(') Upgrade ( ) Abandon ( ) an individual sewage disposal system at F`;' _ t(-F f."-' as described in the application for Disposal System Construction Permit No. -- - dated Provided: Construction shall he completed within three years of the date of this permit.All local conditions mu t:be/met. Date - n,/ x^ .c it - - Board of Health FORM 2 - dSCP DEP APPROVED FORM 5/96 FORM 1255 1 REV 5/96) C HAW yHOURS a WARRENiM PUBLISHERS BOSTON