App-Permit-ComplianceNo.��
FEE
F®WW®NAITICA1LTU ®E MAINAFUTI NUTTIQ
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Board vfHealth, !, MA.
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LIC �[10N FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
p"iicauon for eto Construct(-) Repair( ) Upgrade XAbandon( - ..Complete System ❑ Individual Components
Location
Owner's Name N/ ct ke kVPt vt to °1
Map/Parcel# 136 -
Address I jSGn (.tf)k!C� s�va v-1 -C 4
Lot#(e, f C/ O'Le.c, �k 16 7 a�J 117
Telephone#F�1'j r�. `�1 �. @3 fe �r Q 5��7
Installer'sName/Z.q ICpl fr-,0-4o.-,
Designer's Name h ���/� �j(fr,r% torr
Address y Cw� /1 12ol C'JL-4 1W
Address Z �•Cf, E e �Q >S'"` Q /t'
Telephone# 68-g " T-7 I q-7 5'3 ®
1 Telephone#�Q - -Z S ?y (3 �� 6
Type of Building s t` � y Se �} t ' Lot Size :23 3 Z— sq. ft.
Dwelling - No. of Bedrooms �� Garbage grinder ( )
Other - Type of Building �/r No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min.
Plan: Date
Title 42 DA
Description of Soil (s) S
Soil Evaluator Form No.
Ar L
gpd Calculated design flow X20 Design flow provided "Z -y3
Number of sheets - /� `Z Revision Date
aq /"�Q ti 3`j "� &k�4 RC's r1 tS
_ Name of Soil Evaluator j 4.,-- fVlC it tR Date of Evaluation
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DESCRIPTION OF REPAIRS OR ALTERATIONS �� o l� a!�
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre no ace the system in operation until a Cer 'ficate of C mp 'ance has been issued by the Board of Health.
Signed D �Z
Inspections `� 'yiy '� �✓ 1G/Z , ! (�d� it �6� ��� /�
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No. �� 114 UCOMMONWEALTH OF MASSACHUSET
Board of Health MA.
Cb`
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) )gComplete System tyw �,
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (. )-, <bandoned ( )
by: �caNS c:.'TlOP3 1
at ql'A N ,r" 1-(�, Ve v1 -'% c 1Z '- r
has been installed in accor nce with the provisions of 310 CMR 15.00 (Title 5) and the roved design plans/as-built plans relating to
application No.
16 dated � /� � G� Approved Design Fl9w $pd)
Installer -� P� 1w� i(^ - -- --- ---- CCC f� !�' _ .
Designer: e; aG 1 r- 1 hi -y- WNLKS 1h9G Inspector: 1%40i.IW7_ Date:
The issuance of this permit shall not be construed as a guaran that the system will function as designed.
No. jC y
COMMONWEALTH OF MASSAC14USETTS
Board of Health,MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
FEE
C -41 �-# 5
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(06 Abandon()anindhidua I sewage disposal system
at ::�iei y A s -Rd Vcwi .,- c) -*-11 as described in the application for.
Disposal System Construction Permit No. l, dated
Provided: Construction shall be completed within rej .arsrof the date of this permit. All local conditions must be met.
Form 1255 Rev. 5196 A.M. SS kin Co. Chadestown, MA Date - � " B �aT7 allth �*
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