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o0 COMMONWEALTH OF MASSAC14USETTS
Board of Health, t) J MA.
FEE �- W
f APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
plication fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System ❑ Individual Components
Location
Owner's Name 7,0 5c,
Map/Parcel#
Addressap—
Lot#
Telephone#
Installer's Name M
Designer's Name
Address i
Address
Telephone# _ f+� s�
Telephone#
Type of Building hj" � / - 4c 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) Z -2-�) 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
DESCRIPTION OF REPAIRS OR ALTERATIONS �� 1-a
4 -7 -- /-/U l- A/ — / l� 2� G
To
'.i J.1✓
Date of Evaluation
t
The undersign gre s to install bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree o o plac th tem in operation until a Certificate of C mpfi ice has been issued by the Board of Health.
Signed + !Date e5�
Inspections
No. 111VEiE Q0
4 COMMONWEALTH Of MASSACHUSETTS 0 7 �4-13-3z-
Board of Health, —.__yA}Q j01 nW MA.
CERTIFICATE Of COMPLIANCE
Description of Work: UAndividual Component(s) ❑Complete System
The undersigned hereby certifx that the Sewage Disposal System; Constructed (y!Repaired ( ), Upgraded ( ), Abandoned ( )
by: ('AK&V�
at
has been installed
application No. %
Installer
accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated �� u �'� / Approved Design Flow (gpd)
Designer: Inspector: I i� ✓ _Date
The issuance of this permit shall not be construed as a gutrotee that the system will function as designed.
No. M r-1 6 —1073Z- C4 ('ta„DI�JA L-� NS'TYZ- Y FEE dg ��0
� � ✓� COMMONWEALT14®F MASSACHUSETTS
i� Board of Health, �,r IIn 01 , MA.
DISPOSAL STSTEM ' ONSTRUCTION PERMIT
Permission is hereby granted to.; Construct( ) Repair(�Upgrade ( ) Abandon( ) an individual sewage disposal system
at 1F 741;4&k 4).& as described in the application for
Disposal System Construction Permit No.,/. -/,-/1i S' 'dated. C,�-L7
Provided: Construction shall be completed within trr/a. a -y rs of the date of this per it. All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadeslown, MA Date 4;- Board Of Health '+ �