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No. �7i7 G.� L -g -77,Z -- / ��- /�v �� / FEE
16 d COMMONWEALTH Of MASSACHUSETTS ���`�aa
Board of Health, 4612MQ J7 f , MA. , ,
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
plication for Permit to Construct( ) Repair M/Upgrade(�j Abandon( - ❑ Complete System ndividual Components
.,cation t . n
Owner's Name 6
Map/Parcel# / tee/ , -
Address
Lot# B
Telephone#
Installer's Name
e
Designer's Name. off G
/
Address / 9 9 C �c
Address s^ g A
Telephone#
Telephone# 7 00
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( }
Showers ( ), Cafeteria( )
Other Fixtures
Design Flow (min. required) 3 e Q gpd Calculated design flow Design flow provided 5 7 3 gpd
Plait: Date Z " ,ri Z, 'I6, Number of sheets �% Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator ����� �/��ate of Evaluation
v /<-11
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 t place the sys�vqi in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed
Inspections ) G(/ /isaic;6 u -ilk c-,e'a'
No. 61) C- (o Y/ .
COMMONWEALTH OF MASSACHUSETTS FEE
/ Board of Health, 4472MOT , MA. �-
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereb
2y certify th t it Sewage Disposal. System; .Constructed ( ), Repaired ( ), Upgraded O, Abandoned ( )
by: �d��� fL�A�t C..y�l-•�
at %1✓1 f /
has been installed t a ance w?t the rovisionsfij
off 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �i dated /10. jkpproved Design'Flow %� (gpd)
Installer A4:izoo �t�ze _
Designer: X 014 4 " 1145 Inspector:` � % �i�r'i�� Date:
The issuance of this permit shall not be construed as a guarante that the system will function as designed.
No., ba 03DCI(o 8-72--2. FEE4,5t.6 -- -_
% - - COMMONWF-A .T14 Of MASSACHUSETTS
w Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION ]PERMIT
Permission is hereby granted to; Construct( ) Repair(q Upgrade((-/) Abandon( ) an individual sewage disposal system
at ZZ Al i/ G U v� ti as described in the application for
Disposal System Construction Permit No. : , dated
Provided: Construction shall be completed within three years ort to this per it. All local cot itions must be met.
Form 1255 Rev; 5/96 A.M. Sulkin Co. Chadeslown, MA Date 'd Board of Health !