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COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y/um ( , MA. 1 q"
L
PPdAPP ICATION FOP, DISPOSAL SYST 'l[ CONSTRUCTION PERMIT
A liati fo'r`a�h"n`i to Construct( ) Repair( ) UpgradeJ/ A( andon-, d El System Individual Components
Location
U CC"' lteejel 44Owner's
Name //-i jii`s
Map/Parcel#
1-7 /49-0
Address ?-9 `-q y &;w7 &f
Lot# \10K
Telephone# 61 /
Installer's Name'-- toj�otq�, eO�ts
Designer's Name s
Address ��
/ � � ��� / WIP
Address -oil -/0
Telephone#
Seg- 36'd- &
Telephone# S` G -e- 2 2'p- "j--
Type of Building b+ ,!�► y Lot Size sq. ft.
It
Dwelling - No. of Bedroomsarbage grinder ( )
Other -Type of Building No. of persons Showers( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) OD gpd Calculated design flow Design flow provided �23 gpd
Plan: Date!
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS S' ,P 1&04,he,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of T= 5 and
further -agrees Ok not
two pl a th t?ek� operation until a Certificate of Compliance has been issued by the Board of Health.
Signe ' f\**\ " Date "''
No. � 01+1DC-((o — 9046
0
/�-/L
��✓ FEE `J • C�
CO MM ONWEALT14 OF MASSAC14USETTS R, -
9'
Board of Health, � (� ( , MA 1I l ! t} 41 Gr; 6-0
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ),Repaired 4 Upgraded( ),A bandoned( )
by: L- d' 1 i
at �FT ,�..4 if S CQ1,^1 ,pis f i.i/ '1.
has been installdcl iri'decor ince with the Pr(
application No. 0 - it dated-/
Installer--"� t� (I ;r c i „Qy j
of PO CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
fb. Approved Design Flow f (gpd)
Designer: rQ(Ah Inspector:
The issuance of this permit shall not be construed as a guara
No.a�
Date:
the system will function as designed.
17 COMMONWEALTH OF MASSACIIUSETTS
Board of Health, Y/701_, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE t G'5.. 0 0
sjt%ccies-1,571, 01
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(,;) Abandon( ) an individual sewage disposal system
at Wi i's C. as described in the application for
Disposal System Construction Permit No. 1 - % 9/7 , dated
Provided: Construction shall be completed within th+eei)eam of there date of this permit. All lo6al conditions must be met.
Form 1255 Rev. 5/96 A.M.SulkinCo. Chadeslown,MA Date Board of Health`
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