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
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fy9 Florence irsCrrs%tonne._ M/}orob z
MatilVnrtol 4
Address
sal- 1028
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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.
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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