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COMMONWEALTH CTH Off' MASSACHUSETTS
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Board of Health, to (f MA. �' o ) X_
APPLICATION FOP. DISPOSAL SYSTEM CONSTRUCTION R, ����
Application for a Permit to Construct( ) Repair( ) Upgrade/Abandon( - ❑ Complete System Individual Components
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Map/Parcel#
Address
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Installer's Name 44. i
1signer's Name
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Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms �� Garbage grinder ( )
Other -Type of Building No. of persons 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. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
-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 to place the system in operation until tificate of ,ompliance has been issued by the Board of Health.
Signed Date �`J✓
No,' wW .A -107i 7GCOMMONWEALTH OF
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Board of Health, 6 d7W , MA.�
CERTIFICATE Of COMPLIANCE �G����W� �. �.
Description of Work: -21n--ciividual Component(s). ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ),Upgraded Abandoned O
at =3 .�. l%%.. r r .,,:-r z , d -i9 /� e_ �''� 0 .!�' .� �. �t•s-i--s .
has been 'installgd in acco
application No. .e
Installer
Designer: r4 4 cgt,& c.7
The issuance of this permit shall
No. ha c 0 -77 G
with the provisions of 310 CMR 15.00 (Title 5) atYd the a proved design plans/as-built plans relating to
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dated . "' Approved Design Flow 6 Z (gpdk
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Inspector: Tiate:717
not be onstrued.as a guaran Pliat the system willfunction ads designedS'
COMMONWEALTH OF MASSACHUSETTS
Board of Health,� A?=M o t)7 }f' Am.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Permission is hereby granted to; Construct( ) Repair( ) Upgrade(' ) Abandon( ) an individual sewage disposal system
at irk stir,',? 1� A ...fe as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years Qf the date of this per it. All local co ditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date d - -,-� ,toar8'Of Health fir'" Y
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