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1236 Application & Permit 1997 Nom-17 I3> 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 C £. c 1 CJ Alr L /� (-I' (.1 CJ '.:. iii / r S� wyagpnpleuy ( awn 94/j into/Q9naK4Ja'JA F,. U c ,•q 1 7' j {Pwll '3 J '6- w wwl!Paaa '01/'uuuad WO JO alsP all JO un(avyl 0011!.:-pauldwua XI Ilays ounalulsuo]:P+PPaait w L^a 1-- Z6/0e/// PusP/ / /S ••0N nuufJ uaumlauco wan( , m 1 ... t�,. �J"� guods!Q lol u0n134dda aglul Pagu361(1" ' JJy/ n u?JQ/3 ',E71 ii 1-'.^' z 1° wan65 !withal afi.as ynPMPUI ue ( )uupua4V I ppuidld P<<LJatl ( pawl J :01 pnuea (gang sl uouqusnct A `;: D n) z 20 rJ 1- pY 111VN8d NOI1Jf1111SNOO haLSAS '1VSOdS1a .�, () l, ;? 1 F' ^5 `- F . TN • aajr91'1M1 #1#1/1 'lplo✓0/o P4000 a) c m c* s ''// Cn a cD G is S.LlaSfill3VSSVW M • AO 1111V� NOWWOJ • O =1 0 iJ �'C lad La0011 . 1.p et� oN inSa - z lvaO4 965 IrnW YsWida J33 'p paodlup Sr uul UUn1111.x wan is ay Iw0 aaluuanl Vic Panllwm ay IOU I1s45 quuad MO JO aau•nul ayy p ana muaJwl 'nuilsaa 06 -eZ_S allying 3o NM Nop • (pdl) --.014 u/■ap pa.,wJJV - pauP 'uN uopea!Jde "I &Min wagd 11!agspsuald ul!saP P a.0.419 Pm (9 awn oast n14D DIE Jalug(4041r avyM Ni�ol�6Pig1B unq li °x£ 21 I. • : q i7 ( 1 PluoptuagV'11 PsPuSdfl 1l(Pagsdatl 'l I Puawouo}: a aia.atl alp 0 X4va4 PauInapun ally _ _ ' `\ _ wan;y alaIJwo3 (s),u,uwlmu,g.71. 'Jilt :M,OA,to uugldMand -r%n'�,IN01P @IJNVi'IdwoD JO d,LVJIdl.La7D • �� i VJY ' ta�' 'an'u�'r'IQ 'gownfop•w✓0 I ; S113SnuDVSSVW AOl11'IvaMNOWLVOJ i _�I: