839 Septic Application Permit & Compliance 2004 IJ� THf1COMMONWEALTH OF MASSACHUSETTS Fee 5D'6
BOARD OF HEALTH (�(.OJC. fl'
C \e, of \Ua. At\1/4 :'1-;�A\ FO 1\ ! r"
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT 1
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Application for a Permit t Construe( ( 1 Repair ( I (Ipgradc)) Abandon ( ) - Complete System Individual Components
Type cif Building: .]v ts4\ :; Avg(\VaA4 e AiLQ Lot Size Sq. feel
Dwelling—No.of Bedrooms �' Garbage Grinder ( )
'' Other—Type o uilding No.of rsons _ ( ).Kafeteria4 )
Other ftxlu - _a-Showers t
Design Flow(min.required) 3 t-' gpd Calculated design flow - gpd Design flow provided S gpd
Plan: Date \ 1G (lc A,U Number of sheets 1 Revision Date
Title
Description of Soil(s) i l l v'e \c \ \ - :'A C▪e ✓ C-",C v-y/ t4
Soil Evaluator Form No. ( Name of Soil Evaluator 44`, VI'.k`ati Date of Evaluation I-} '0-3)(
DESCRIPTION QF REPAIRS OR ALTERATIONS \ �CA\\ t .> u ) I S "-.�'e(
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= s 1 :C \-'�vAk vA ,. .L L�`e))VX - A II" ' X`-IU ' \w"1/2 '
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The undersigned agrees to install t ii above described Individual Sewage Disposal System in accordance with the provisions of
TIRE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued b the Board of Health.
r.� s/1,%o y
Signed -=�" v"�" Date
Inspections
FORM I - APPLICATION FOR DSCP DE.P APPROVED FORM 5/96
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Type cif Building: .]v ts4\ :; Avg(\VaA4 e AiLQ Lot Size Sq. feel
Dwelling—No.of Bedrooms �' Garbage Grinder ( )
'' Other—Type o uilding No.of rsons _ ( ).Kafeteria4 )
Other ftxlu - _a-Showers t
Design Flow(min.required) 3 t-' gpd Calculated design flow - gpd Design flow provided S gpd
Plan: Date \ 1G (lc A,U Number of sheets 1 Revision Date
Title
Description of Soil(s) i l l v'e \c \ \ - :'A C▪e ✓ C-",C v-y/ t4
Soil Evaluator Form No. ( Name of Soil Evaluator 44`, VI'.k`ati Date of Evaluation I-} '0-3)(
DESCRIPTION QF REPAIRS OR ALTERATIONS \ �CA\\ t .> u ) I S "-.�'e(
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= s 1 :C \-'�vAk vA ,. .L L�`e))VX - A II" ' X`-IU ' \w"1/2 '
a (,\C.\\\9 (e,,.
The undersigned agrees to install t ii above described Individual Sewage Disposal System in accordance with the provisions of
TIRE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued b the Board of Health.
r.� s/1,%o y
Signed -=�" v"�" Date
Inspections
FORM I - APPLICATION FOR DSCP DE.P APPROVED FORM 5/96
Nn. G I ' I THE COP NINE LTH OF MASSACHUSETTS
y i BOARD OF HEALTH
CERTIFICATE OF COM$LIANCE
Individual Component(s)
Description of Work:
❑ P
The undersigned hereby certify that the
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at
has been Installed in accordance kith the provisions
plans relatim to application No.OLD1-4/ dated
d,.. ,
omplete System
wagepispesal Ss stem onstructe� ),Repaired( ).Upgraded( ).�jf''baion
/ /_19-* dJ
Installer
U CMR 5. O 'itle
Designer: i-AI<c '- Inspector a a.
and the approved design plans/as-built
Approved Design Flow (gpd)
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. 7 Li<i//—��
THE COMMONWEALTH OF MASSACHUSETTS FEE �C.- .d(
/1/G/ZJ7bV1 PR BOARD OF HEALTH C1--^-L 4 j5; %
DISPOSAL SYSTEM CONSTRUCTION PERMIT 6'€
Permission is here. • granted to Construct ( ) Repair (jUpgrade (C--/Abandon ( ) an individual sewage
disposal system at ' .2 r as described
in the application for Disposal System Construction Permit No. %OD U!— 17 dated U! — 3 6 -'o V.
Provided: Construction shall be completed within three years of the date of this permit 111 local csnditions must be met.
Board of Health
Date ns 20 hLI
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 7255 REV 5/ SJ
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HOB&sb WARREN
ERN
PUBLISHERS - BOSTON
1. Afr'•.1. RS, NS,
DIRECTOR OF Kiwi