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FEE
COMMONWEALTH Of MASSACHUSETTS ck+ G'75 -
Board of Health, %mrb , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (vY"'Upgrade( ) Abandon( ) - ❑ Complete System l 1'I vidual Components
Location
Owner's Name M \ulen,
Map/Parcel# �� Z'�
Address6 0\6 b S'{lR
Lot#
Telephone#
Installer's Name `
Designer's Name
Address Inww \
Address
Telephone# 60'6- -7 q
Telephone#
Type of Building z-\1oti Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No,
gpd Calculated design flow
Number of sheets
Naive of Soil Evaluator
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS c b �`
agSF /(9 /5t -t) /L51,�L 6 1kX1Xe
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to nott"lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed / .i �"`� -� Date
Inspections
No. �C3k�DC-g7�� Ale �
E(�—'
SCOMMONWEALTH Of MASSACHUSETTS JEE
Board of Health, 1aC'ii o l�1 MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constilucted ( ), Repaired (�' Upgraded ( ), Abandoned ( )
by: �'C cy�'C � rICr,
at
has been installe in cord e with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �1 �.� dated Approved Design Flow "" (gpd)
Installer
Designer: `Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 80" -DC -ho -0-7757 - cpCj J e-qp C SVCS, FEB 00
COMMONWEALTH OF MASSACHUSETTS
Board of Health,i��(�t1C) �� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair{ vj Upgrade( ) Abandon( ) an individual sewage disposal system
at �`;� ���t�° C \C / 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. Alllocalconditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board Of Health