7 Title 5 Application/Permits 2005 No /al `-fit
THE COMMONWEALTH OF MASSACHUSETTS
ARD OF REALTH
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APPLICATION FOR DISPOSAL STEM CONSTRUCTION PERMIT
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Application Ior e Permit to Construct ( ) Repair I 1 Upgrade ( don ( ']Complete System [Individual Components
Type of Building:
Dwelling—No.of Bedrooms
Other—Type of Building
Other fixtures
s3;-:
Lot Size / /f/ Sy.feet
Garbage Grinder ( )
No.of persons Showers ( ). Cafeteria ( )
Design Flow(min.required) ei Calculated design flow gpd Design flow provided gpd
Plan: Date 0,� 1/20e er of sheets Revision Date
Title
Description of Soil(s) /�
Soil Evaluator Form No. v of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS O A TERATIO S a ` s/a .W ry
The undersign- agrees to install t above described Individual - age •isposal System in accordance wi the provisions of
1111E 5 an -s not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
(gwti ignetJ ki DateA
Inspections —
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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Type of Building:
Dwelling—No.of Bedrooms
Other—Type of Building
Other fixtures
s3;-:
Lot Size / /f/ Sy.feet
Garbage Grinder ( )
No.of persons Showers ( ). Cafeteria ( )
Design Flow(min.required) ei Calculated design flow gpd Design flow provided gpd
Plan: Date 0,� 1/20e er of sheets Revision Date
Title
Description of Soil(s) /�
Soil Evaluator Form No. v of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS O A TERATIO S a ` s/a .W ry
The undersign- agrees to install t above described Individual - age •isposal System in accordance wi the provisions of
1111E 5 an -s not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
(gwti ignetJ ki DateA
Inspections —
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
215'
en
THE COMMONWEALTH OF MASSACHUSETTS
/&7)f ;) BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: Er Io ividual Components) ❑Complete System
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The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired( ).Upgraded
by: s2
at / / o t <' 9".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. l4 dated ,v tl4y — -Act C. Approved Design Flow 1,)4,4- (gpd)
Installer I Lti^3 4313/NO /
Designer: �Zi/// �- Inspector Y,,.=^-�wz-++IY%C Date /��%v _
The issuance of Ids certificate shall not be construed as a guarantee Thor du system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
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No. 2/ _/y
THE COMMONWEALTH OF MASSACHUSETTS
±e tom- yar-,a rt_ BOARD OF HEALTH
DISPOSAL SYSTEMCONSTRUCTI N PERMIT
Permission i5 hereby granted to Construct ( � epan ( f ffpgr`(tide ( ')f dntisii dt j an mdmdual sewage
disposal system at 7 /r /.-'! , - as described
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in the application for Disposal System Crn(snuction Permit No. „ , ,dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
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Date
al Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255IREV 5196)
L W� HOBB6&WARRENIn'
PUBLISHERS- BOSTON