731 Septic Application Permit & Compliance 2006 GNV
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TOZ ev`I D OL Fu.JLlii
No. dO"6..a7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
■ Y OF o.-�
C ry
P4aM
oh re
e.4, 51
—� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
na Application tor a Permit to Construct ( ) Repair f)Q Upgrade ( ) Abandon f ) -,KComplote System ['Individual Components
Dwelling—Na of Redman-Is
Other—type ofBuildine
Outer fixtures
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Natant rr Nnm.,
AJar a.
It-'�O.
No.of persons
Lot Size Sq. feet
arbage Grinder
Showers ( ), Cafeteria
Design Flow (min required) 3O gpd Calculated design Clow gpd Design flow provided gpd
Plan: Date In) 1�o )oco Number of sheets I .?y'"X/B` Revision Date
Title • rs.•. t
Description of Soil(s) (-k—p.. —�r -9 r lL,
Soil Evaluator Form No. A/ /A �.Vj ante of Soil Evaluator In /,w/n,t_i Date of Er uatmn
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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
* 1-- e. P(. ct '. IOJZZJOt
ft'i i, 1` i9 fr.. 1'ft Tf- L -.
Inspections
FORM I - APPLICATION FOR DSCP
DEP APPROVED FORM
NORTHAMPTON BOARD OP H A TH
Afforrow r-
Ernest 7. Mathieu,RS..M.S1 Qj.O._
No. 9
THE COMMONWEALTH OF MASSACHUSETTS
-yJ b`'2`1teCi itr1) BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) %Complete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired(»Upgraded( 1.Abandoned( )
by: f a z ' ' - S r ,)6- h 5 H- .21: Q// /1-Ail> Tn(Ydy-al;
at r2 a,l t ,/,)6-7-:
ti-/P - 4- ,t2/ , .%� .,r;n7% i/7 / tr.P-'t
has hccn 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 fi)L- '(dated Approved Design Flow ':5:., (gpd)
Tl F1itf [
Designer: / , 1. _ / f- %A U/CJ 6.14dt CS Inspector ,r - .1 1CLZC Date /Q!/e✓ iF 1
The issuance of this certificate shall not be construed as a guararVee fhal IL Y rem will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
THE COMMONWEALTH OF MASSACHUSETTS
;
- BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair (�') Upgrade ( ) Abandon ( ) an individual sewage
disposal system at % ! / --,T-n —' A— i:-/— as described
in the application for Disposal System Construction Permit No. %/ - 7 .dated / //,
Provided: Construction shall he completed within three Years of the date of this permit. All local conditions must he met.
Date
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 IREV 5/961
NHS W) Hoaes a WARREN
Board of Health
PUBLISHERS - BOSTON
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Commonwealth of Massachusetts
City/Town of MoRM-HntrelD J
Certificate of Compliance
Form 3
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
This is to Certify that the following work on an On-Site Sewage Disposal System
❑ Construction of a new system
® Repair or replacement of an existing system
❑ Repair or replacement of an existing system component
Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
DSCP Number
Patel
Facility Owner
731 Florence Road
DSCP Date
Street Address or Lot#
Florence
City/Town
Designer Information:
Michael Lavigne RS c�Q',
Nam
iko ,k R.S •
Signal l/ /
Install ormatlor✓
JameSQDimos
Name
0
gnature
Ma.
State
01062
Zip Code
Environmental Design, Inc.
Name of Company
October 16, 2006
Date
J.C. &Company Inc
Name of Company
e / 7
Date
✓ Use of this system is conditioned on compliance with the provisions set forth below:
The final inspection was conducted by Timothy E. Mginnis RS. because Michael Lavigne was not
available. No garbage disposal allowed
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
Approving Authority
Signature
t5form3.doc•06/03
Date
Certificate of Compliance•Page 1 of 1