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292 Application & Permit 2006 No. (7(7//[ V r ciR 01A WiIS0/1 ds p THE COMMONWEALTH OF MASSACHUSETTS FeF '' rL' G l r , F micrtmoinivi Iva Uti* t31BOARD ,OFHEALTH APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT ,vnnI irnn fora Permitto Construct XRc'airL ) Upgrade I 1 Abandon I I - mplole System L Individual Components �,y�Q�aip it .-Tv l A. AO -.3 L'LD N%CSCAjL a, , • .,;r a/ 3r( I + /N6y^ 3,� r, A!,5c��xxs Ms. ' � li rj.: fa DiL6z 679 Aid rw e a.i / 1 5P6-4h7O 6 mAimmi_., it id I i°(� ,A.4 A -- bea d3 Zc<�� 7 e am y CO. Bx 3 tdr,4)tti _rz ro 4i( 3 '�(' . % oy *413 73 "- .5323 Type of Building:_ ALL-S r19GL a-L Lot Size Sq. feet Dwelling—No. of Bedrooms S/h Garbage Grinder (4 Other—Type of Building Y,C. _ No. of persons N?/__ Showers ( ). Cafeteria ( ) Other fixtures A/A9-- Design Flow ( n r (uired) �6 0 ,,pd Calculated design floe 0 Bpd Design flow provided 64clopd Plan: Date 3J`�77/C & Number of sheets ti Revision Date TitlesSie-7v pr5 .S9t-SyS M 4-r LO 3 OLD kin 4,1'10 fro. A 74t Pryaa*4 444L Description of Soil(s)_ WO'( Ldp}_fcn-# � ®�� Soil Evaluator Form No. A 4_/Z Name of Soil Evaluator AA, 44/2 —‘z Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 4/6w Coilflu%ZC'w /NGtJ-iO zsoZ- &&t ' J 56-17fici7-A", 4-8 41617'0-5f „ +5eD 6173 Lcrfeyy � Ada 4pa-nn yet CCA/NEC V - The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to,lace the system in operation until a Certificate of Compliance has been issued by the Board of Health. ///C 4 2 F� Z ra.0 6, Signed Inspections Date FORM I - APPLICATION FOR D5CP DEP APPROVED FORM /96 No Description of Work: THE COMVONWEALTH OF MASSACHUSETTS ! jq „? ' ifro A OARD OF HEALTH CERTIFICAtE OF CO LIANCE Individual Component(e) Complete System r(/ FEE / V PM ` l1 // /; a. The undersigned hereby certify that the Sewage Disposal System:Constructed I4 Repaired( ).Upgraded( ).Abandoned( ) at has been installed in accordance with yhe previsions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No %oAT dated_ / i Approved Design Floe. / 1 (gpd) Installer / Designer:41Clts(si' Inspector i {d/✓. The issuance of this certificate shall not be construed as a guarantee thaf4he system will function as desi FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 `'A No. o' THE COMMONWEALTH OF MASSACHUSETTS v' /f�,,.�� � /I BOARD OF HEALTH DISPOSAL SYSTEM,CONSTRUCTION PERMIT Permission is hereby grganyed to Constyuct (I j Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at !</C C'i 1-L( v' .ct 1-_xv - - as described / in the application for Disposal System Construction Permit No ✓i i j .dated `, 12.1 r Provided: Construction shall he completed within three years of the date of this permit. All local conditions must he met. yl?// utC 1-1<, Zric f /!;/” Board of Health � i0Za-s ;7//-/r Date FORM 2 - DSCP FORM 1235 (REV 5/96) DEP APPROVED FORM 5/96 HAW i) Noma n WARREN II" PUBLISHERS - BOSTON