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17-x/ COMMONWEALTH OF MASSACHUSETTS
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Board of Health, �/�,iVLC�� � , MA.
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PER J�„
A plication fora Permit to Construct( ) Repair/Upgrade( ) Abandon() - ❑ Complete System Individual Components---
Location ICIA
Q
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name Cape
(S C e
Designer's Name
Address D- V
66 6
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Address
Telephone#, '0 Z -VO
ZVOO
7V - -7Zq,-T-7?3
Telephone#
Type of Building ?�s 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) '97 gpdCalculated design flow Design flow provided gpd
Plait; Date Number of sheets Revision Date
Title
e
Description of Soils) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR
The un4
further
Inspections
Name of Soil Evaluator
Date of Evaluation
In . ' ual Sewage Disposal System in accordance with the provisions of TITLE 5 and
until a Certificate of Comhance has been issued by the Board of Health.
- � - 2- Y l7
No. ±A��—,. /� ��^1FCX:G"*• J,�//�FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, N NUAC) LMA MA,
CERTIFICATE Of COMPLIANCE
Description of Work: /Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O Repaired (Xpgraded O, Abandoned ( )
by ++ C err 12 �G r !%� t ( '- S r c C)1')
at _1_ l (i' f)11 c
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. dated _ F % 7 . Approved Design Flow-i')(gpd)
Installer-r')Cl(0 ,/7 'e?
Designer: Inspector: � f Date: /
The issuance of this permit shall not be construed as a guarap ee that the system will function as designed.
No. FEE G/ C.J
COMMONWEALTH Of MASSACHUSET TIS
Board of Health, �jTA O l)'- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(VUpgrade ( ) Abandon ( ,) an individual sewage disposal system
at ;,/ Cl ,li k,,l .f) i as described in the application for
Disposal System Construction Permit No. / �J i dated 2 ...6'% 7
Provided: Construction shall be completed within ars of the date of this permit. All local conditions must be met.
Form 1255' Rev, 5/96 A.M. Sulkin Go. Chadestown, MA Date,, -' / Board of Health