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No. O ' -7-22j�
6(-17�-r-) 60-3606
FEE
7 COMMONWEALTH Of MASSACHUSETTS
Board of Health, ZA2/Y10 unf 111,M.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
A plication for a Permit to Construct( ) Repair( ) Upgrad bandonO - ❑ Complete Syste dividual Components
Location a a. 01 I% v el< JI S LA b- � F• .,A 9 6+-t) to
Owner's Name t3 p 5 a e -*4
Map/Parcel# M n b e Loc.K { i
Address Patin" z%o t a -2z n.as DA , h A OA 3:L
Lot# 8 v 4jtt (o
Ir
Telephone# do ZS q - SSS 6
Installer's Name N o2L-h,•e 4-s,+ Catt64v-v.+1--1'
Designer's Name jry) Q 1 Re- t I l }- �SS oeG�s T6f C
Address(Do r3oK d3so r3R.rwS4-r2'rnaQL63l
Address PG Qo>< 1ZZ3 leu. a= , A 02G31
Telephone# 6-0 9^ 5 Q 6 - 7 7 1,-
Telephone#
Type of Building Co
Dwelling - No. of Bedrooms _
Other - Type of Building
raj
+-t,i- I -
LotS'z sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) U gpd Calculated design flow Design flow provided gpd
Plan: Date % % a i IL Number of sheets Revision Date
Title �' l 4' to 1- 15 64
Description of Soil(s) A, 1.t C/
Soil Evaluator Form No. Name of Soil Evaluator A, c•ec-xt' 1'ly Date of Evaluation d
P - ap-1,Vj,0I-&ti3at)
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersignedagrees o install the bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to lace the em in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
L,F CCC
No. /FEE
COMMONWEALTH OF MASSACHUSETTS 6X- I M
/ l�
Board of Health, YAD(i T�J� , Mby
A. 1
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System _I
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded' ( ), Abandoned ( )
b 1,..; C , t I t C- )� `> rt +^
Y�
at 7
has been installed in accordance with the provisionp of kQ CMR 15.00 (Title 5) an� hg,
application No. -roved design plans/as-built plans relating to
' U
:.` dated f ' Approved Design Flow (gpd)
Installer
r
Designer: ) t` ' l.. jC ! t t ' 1 l �> Inspector: _ t f ;`t Date:. r °
The issuance of this permit shall not be construed as a guarantee that the system willfunction as designed. _
No. t C' _ ! .(� !Lt .���r�e:-r (�?�j 1�F�{C.�r� FEE
.�� 7 COMMONWEALTH Of MASSACHUSETTS C" 7 2-'
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j
Board of Health, y/-)' g -M D V174 , MA.
DISE®SAI. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade() Abandon( ) an individual sewage disposal system
at -tI a L A i\,, P� �� � � �- � f ' �C as described in the application for
Disposal System Construction Permit No. ( 7 , dated
Provided: Construction shall be completed within tkrei�-Vears of the date of this permit' ocal con tttons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board of Health /