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� �17- ®MMONWEA1114 Of MASSACHUSETTS �
Board of Health, _'( �J� ., ., zr1- �.t MA. j71* L C�
r wl caAPPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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App)it�iogh f r a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( M-Iff'omplete System ❑ Individual Components
Location fL
Owner's Name
Map/Parcel# a---
Address 6
Lot# j+7
Telephone# �Vr,
Installer's Name
Designer's Name
6
Address
Address P
Tplephone# C- Y110,Telephone#
Type of BuildingLot Size e Z sq. ft.
Dwelling - No. of Bedrooms �3 Garbage grinder (a -).O
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) % /0 gpd Calculated design flow 3 3 e, Design flow provided 3f!? � 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 rN .,.i 12f NE- ,11%• c S1 .STS r,4 Z-5-0-0 GS 7-
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees not to place the syste/m in a eration until a Certificate of Compliance has been issued by the Board of Health.
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Signed 1l,ta�.,1Aoi Date c - Z! 2 15t
F fie- , S, Klckm -
Inspections
No; GI/ % FEE //IV. (/C/
COMMON LTH OF MASS C14USETTS
�'```•; Board of Health,, MA.
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MPLIANCE OV
Description of Work: ❑ Individual Component(s) fU�<omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed, epaired ( ), Upgraded ( ), Abandoned ( )
at
has been installed i
application No. G
Installer
•oved design plans/as-built plans relating to
(gpd)
Designer: Iector: `'�Gt.X�C Date:
The issuance of this permit shall not be constr , efi d as a guarantee th t the system will function as designed:
No. (/ li / / �� IS oiC C tet„
C®MMONWEALfIl OF MASSACHUSETTS
Board oflVth, V cam' MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct (,X Repair(
at /_ ✓$7/z -
FEE'
%%fir C CG-1�1I/9-it�
Upgrade( ) Abandon( ) an individual sewage disposal system
Disposal System Construction Permit No. `�U� dated -3 G�
as described in the application for
Provided: Construction shall be. completed within three years of the date of this permit. All local conditions mus be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ,: (Aoard of Health'
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