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Board of Health, 1946 ROUT 28MA.
APPLICATION FOR DISPOSAL SYSTEM MWIPCTI®N PERMIT
Application for a Permit to Construct( ) Repair(e�upgrade() Abandon() - LlComplete System 6T. -d iidual Components
Location l £ N/S 2 L N S p f�Of/p
Owner's Name e Q/f C&
/e Th /y
Map/Parcel# 6'7 -b
Address D £-ou/sF
Lot#
Telephone# 5'470'• � $-
Q(c3
Installer's Name tf �(/ C, p
Designer's Name
Address 3SV 1)*�/,v j7-• w
Address
Telephone# ,SV Y - `% ) S ^ t�L 9'49 4
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
o ✓,$ Z
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS E �i C �/ f IWI'�V/f �Ao �o
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ato not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date —/Y,
Inspections
No. 9� FEE
COMMONWEALTH EALTH Oft' MASSACHUSETTS
Board of Health, %%'e , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 611vidual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (`Upgraded ( ), Abandoned ( )
by: 14 d Z ('11/L/C D —35--9 77— 6' ` �/ Ile
at l 2)iA115F )-4. S.9 -WP
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
applicatiory-No. , datp4 Approved Design Flow (gpd)
Installer
Designer: Inspector: l Date: /I�z
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. t FEE t " C
Board of Health, T �,MA.
DISPOSAL SYSTEM CONSTRUCTION
PERMIT
Permission is hereby granted to; Construct( ) Repair (4-T" Upgrade ( ) Abandon ( ) an individual sewage disposal system
at I F ��S E 4% So Vd4 0 as described in the application for
Disposal System Construction Permit No. dated / L
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / L Board.of Health