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41
FEE-
COMMONWEALTH
EE_COIF MONWEALTH OF MASSACHUSETTS'7- 0 �
t
Board of Health, Yifi•2ME QT0 , MA. />b (' 14tel Z1
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) Upgrad,�,/Abandon( ) - ❑ Complete System 0 Individual Components
Location
Owner's Name
Map/Parcel#
Address Pei
Lot#
Telephone#
Installer's Name
Designer's Name felt z Z404-2
Address �� ��-' f
Address PO
Telephone#��.—� `17, _/Ag
Telephone# �1 ��%�--3 dam" k- 3_
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) L330 gpd Calculated design flow Design flow provided gpd
Plait: Date Number of sheets Revision Date
Title
Description of Soil(s) e�- zk_
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 agr s to not to place the system in operatio ntil a Certificate of Compliance has been issued by the Board of Health.
Signed Date _
Inspections
No. -� --'-. " TFEE V U
COMMONWEALTH OF MASSACHUSETV,-_�_
1214
Board of Health, , MA. :Z)
CERTIFICATE Of COMPLIANCE
Description of Work: Zmamdual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,(. Abandoned(
by: 1A r, t/ � {
at r f
has been installed in accordance with the provisio s of 310 CMR 1%00 (Tf7de 5) an he-ap oyed design plans/as-built plans relating to
application No. dated . Approved Design Flow (gpd)
Installer f' A fe s zr
Designer:
The issuance of
Inspector:
Date:
permit shall not be construed as a guarantee that the system will function as designed.
w.
No. 60#FEE
2 Aet COMMONWEALTH OF MASSACHUSETTS (01
Board (f Health, V A lzmoa r cu MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade.( Abandon( ) an individual sewage disposal system
ati as described in the application for
L, n
Disposal System Construction Permit No. Vi dated
�,���
Provided: Construction shall be completed within_t�-s of the date of this perruNt. All local conditioLis must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadestavn, MA Date tp Board of Health