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244 Disposal Construction Application 2010
No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF{ ,,HEALTH OF ' JO(AI 1U.U►"1 APPLICATION FO DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( v)/Upgrade ( ) Abandon ( ) - ❑Complete System ]Individual Components T-4 -t aievloA mol (A /.t. Cda,+�cc Locatio Owner's Name Ma.p 19 �BM► -. OD,S X44 /,a, fid, N ort1ha.nwto o 1 neo Map;Parcel# Address ©01 C4{3) a 3' -3 j s Lot# ''SS'' ii-- --.. Telephone �O InSLL 1 �Tl-1ETt'�{� �Y11/t�Dif� Installer's Name Designer's Name PO x CAD eC) o 3 , C x-fIeki,MA oto Addressddress 13) 53 3 —CO3 4-y- Telephone# Telephone# Type of Building: ftSik.VIPe, Lot Size Sq. feet Dwelling—No.of Bedrooms .S --Erttrb•age-Gziacler.4_4_ Other—Type of Building No.of persons Showers ( ). Cafeteria ( ) Other fixtures Design Flow(mita.required) 3 3 0 gpd Calculated design flow 3 I l gpd Design flow provided 3 9 gpd Plan: Date Ip Number of sheets Revision Date Title S t Loctc t_ tS etst Q St�c1e$-\ P3 ye-re l_ Description of Soil(s) ei to A-CiNi_01 Soil Evaluator Form No. Name of Soil Evaluator it,S`L\ 14 S fOrasDate of Evaluation 4/ 3 11 D DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and agrees not to(place the in 'on until a Certificate of Compliance has been issued by the Board of Health. Signed x.41 l Date Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System:Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: at 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. dated . Approved Design Flow (gpd) Installer Designer: Inspector 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. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. ,dated Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met. Date Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) j1� HOBBS&WARREN " PUBLISHERS- BOSTON