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COMMONWEALTH OF ASSAC14 SETTS
Board of Health, )6)1?�}± , MA.
APPLICATION FOR \DISPOSAL SYSTEM
Application fora Permit to Construct( ) RepairsO Upgrade( ) Abandon( )
FEE `PSV 4 n0
asd
CONSTRUCTION PERMIT
❑ Complete System ❑ Individual Components
Location
7�eOwner's Name
Map/Parcel#
Address
Lot#
Telephone# F
Installer's Nam
E! Designer's Name
Address
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
—2,-
No. of persons
Lot Size
sq. ft.
_ Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t to place m in operation until a Certificate of Com liance as been issued by the Board of Health.
Signed Date_3 Z 3:/ 141
Inspections>� . C'� — e� ' �� �L�/T/�✓ �� l
/v I u 4_ 6 v,-� Jo ct .� i) l o t ! '" /:-)'IT— J 11 q �L' J �1.L.1 ,Ar r I h LVL +(Z - V 1�
No. (o}} 1pC (00 `is
t3�
FEE S' •00
COl�l� ON�1LT14®F MASSAC9SETTS � � c.. -4
Board of Health,
Description of Work:Individual Component(s) ❑ Complete System "' c lS 6V F
The undersigned her y certify that the Sewage Disposal System; Const a cted (. ), Repaired ), U graded ( ), Abandoned ( }
by:
at 11�---
has been install
application; No.
Installer 3_0I
Nth fheyJV6Astk7ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated !I—%/" %g:�`. Approved Design Flow 2__)•,f) (gpd)
Designer: Inspector: ice+ """ Date:�°'� ell L
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. j;_,0 0C. -( A v FEE _ .0
/ – 6 COMMONWEALTH OF MASSACHUSETTS ck; C -s a0
Board ,of Health, A -LM OU-ni , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system
at a 7 i <" e Hw5,c- CZ--bas described in the application for
Disposal System Construction Permit Noy tor. � �, dated
Provided: Construction shall be completed within r+ th Aate of this permit All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesfown, MA Date Board of Health C�