1236 Application & Permit 1997 Nom-17
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FORM I - APPLICATION FOR DSCP r�
reel' 'l% —�
COMMONWEALTH OF MASSACHUSETTS
Board of IlenWt, Nc r T L/n tegint . MA.
E
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for•Permit to Como-kW()Repair,*Urgnde( ) Abandon( ) • ❑ Complete Spurn %Individual Components
Type of Building J -0-t+g, (q 11C✓Se MI Sire sq.'s.
Dwelling-No.of Bedrooms .3 1 Gashege grinder( ) yes
Other•Type of Building No. of persons Showers( ), prnerin( )
Other Fixtures
Design Flow( in. inquired) i?4 grd Calculated design Mw5I6 gM
Ron:Dale�j y92 Number of sheet I Revision Date
Title
Design flow pmrided_god
On-44t- tr >IOesaf Sy c &r2 ,pqi '
Soil Evalustor Fomt No. Name of Description or Soil(t) _ .. Evolostor B ,_ vl..,.� Doe u..-n....,..
_r
DESCRIPTION OF REPAIRS OR ALTF,RATIONS 5< 0 PVc <es 4-
i r -Fcc 2.'I.o' 3 access
t . _
m oak( +
rise/s GVrs
IoJ :K
The undersigned area to Imnll the above described Individual Sewage thyme!System In accordance with the prorlalnm of TITLE
5 and further ayQes not to plate the ste r1)In operation until•Ctrnfcate of Compliance has been bused by the Board of Ilealih.
--/-Signed
Inapecllorw
Date
p. DEP APPROVED FORM 5/96
sn-97
No.
FORM 3 - CERTIFICATE OF CM JkN E
ii:zy Pee
3(e
f j or-ev)CC i`o!
Owner's Name Frank rowrrlier
Address /23(c F/Orencc Ad) Ntft#4a.44l11-17”l,
Location 12
Map/Parcel/
Lou
Telephone/ ( H13) .5-e7— 0(7P DI000
Insuiler's Name
[)cn
(/Jan1a
Prr ho.'a( C $4- 86.12. Sittc:
Uaigneis Name F%m h<rs, rich/ F.str nec.c l a
Addnn
Address f 0.6oX 33i2..)4almea#, unit
r.,,,,,,a,,,g
Telephond<412)2.56-3400° i ooH-37(Z
Type of Building J -0-t+g, (q 11C✓Se MI Sire sq.'s.
Dwelling-No.of Bedrooms .3 1 Gashege grinder( ) yes
Other•Type of Building No. of persons Showers( ), prnerin( )
Other Fixtures
Design Flow( in. inquired) i?4 grd Calculated design Mw5I6 gM
Ron:Dale�j y92 Number of sheet I Revision Date
Title
Design flow pmrided_god
On-44t- tr >IOesaf Sy c &r2 ,pqi '
Soil Evalustor Fomt No. Name of Description or Soil(t) _ .. Evolostor B ,_ vl..,.� Doe u..-n....,..
_r
DESCRIPTION OF REPAIRS OR ALTF,RATIONS 5< 0 PVc <es 4-
i r -Fcc 2.'I.o' 3 access
t . _
m oak( +
rise/s GVrs
IoJ :K
The undersigned area to Imnll the above described Individual Sewage thyme!System In accordance with the prorlalnm of TITLE
5 and further ayQes not to plate the ste r1)In operation until•Ctrnfcate of Compliance has been bused by the Board of Ilealih.
--/-Signed
Inapecllorw
Date
p. DEP APPROVED FORM 5/96
sn-97
No.
FORM 3 - CERTIFICATE OF CM JkN E
ii:zy Pee
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