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No. %+Dc— FEEW�
1,01—"20J COMMONWEALTH OF MASSAC14USETTS
Board of Hea
�'((}R•MLi liTib
lth, MA.ec
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to ConstructO Repair U radeOAbandon{) - ❑Complete System -@'Individual Components
A-
Location L b 905111, l W rf, j. _5,A4 AI I
Owner's Name D _ �61ko l
Map/Parcel# j�6 ��
Address ?-% S Ave -
Lot#
Telephone# 5'0 T 7 2 -
Installer's
Installer's Name $ r�� ,
Y
Designer's Name
Address Zq 6re4a-1,LP +e -r,-\ PJ
Address
Telephone# 5b9' -,S-0'7- 11o50
Telephone#
-_ pp
Type of Building -5 CIA -CO' ( /Al' C', �ti+�-� r 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
Plan: Date Number of sheets
Title
Design flow provided
Revision Date
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OFREPAIRS ORALTERATIONS
L1�6,
gpd
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 tem in operation until a Certificate of Compliance has been issued by the Board of Health.
s Signed W_s>t��.:��, Date
Inspections
No.O% F FEE L Y
—43 COMMONWEALTH OF MASSACHUSETTS
Board of Health., -i 1A -2-M Q tS 11+ , MA. �' y r,
CERTIFICATE Of COMPLIANCE ITw,,c,)t'-j- r�
Description of Work: individual Component(s) ❑ Complete System l
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (b7, Upgraded'( ), Abandoned ( )
by:, j!Z01V-r ' J�JW-P LD ,7-rl /e
at dT/t l/7 i�1�" 1 A i d't'?76� I1 /Ori
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. -A ' , datedApproved Design Flow (gpd)
Installer f-l-i-0.IST�;P1-4%�' n
Designer: .Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 6awpc-1/2, �, ouz FEE "I VQ
C e 3 COMMONWEALTH OF MASSACHUSETTS
Board of Health, 0 t,M:� -, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair(VI Upgrade( ) Abandon( ) an individual sewage disposal system
at - o 41* Q G 1, el C lY) w e.1 ! R as described in the application for
Disposal System Construction Permit No. , dated c'` " %'mac
Provided: Construction shall be completed within three years of the date o this -permit. All local conditions must be met.
Form 1255 Rev.. 5/96 A.M. Sulkin Co. Chadeslown, MA Date r/L Board of Health