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SCS. YARMiOU TH NIA 02H4
C®MMONWEALT14 OV MASSAC14USETTS
Board of Health, GLt Kt. a "A- , MA.
FEE �Q
�,kd 3-7101
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location/6 ,-' f.W j p 1,41W
Owner's Name
Ame-S
Map/Parcel# _ %Q �
Address
W MI L
Lot#
Telephone#
8(U "I — wS
Installer's Name
Designer's Name
Eno
Address 350 Main Stmt
Address
Telephone# W, TormouEn, MA 026ZS
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Lot Size
sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) G� 3 d gpd Calculated design flow 3 t{ b Design flow provided-' C( O gpd
Plan: Date a -a 3 G Number of sheets Revision Date
Title
�!
II I
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
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
further agrees to not o la a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed leek_ 4 Date
Inspections
No. \/ COMMONWEALTH Of MASSA 14USETTS + FEE i U
Board of Health, /44 vk e -/ a- (A, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (0' Upgraded ( ), Abandoned ( )
by: ��/ I e- p
at
has been installedccord nce with the provisions f 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �!` , dated 0 r � . Approved Design Flow 3410 (gpd)
Installer +71 � 0
Designer: Z1,0 /% %y'loL C1VA1 Y, Inspector:Date:
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No. C A '_ !� /� FEE
C®MMONWFAIT1 Of MASSACHUSETTS l4-;�-7® 1
Board of Health, A011.0v¢ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby
at
to; Construct(
Repair (.•-�'�Upgracle (
Abandon( ) an individual sewage disposal system
Disposal System Construction Permit No:�, dated '��
as described in the application for
Provided: Construction shall be completed;within three years of the date of this permit. All local conditions must b" met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -10 hrK Board of Health