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PV -I LUMMUNW LIH U� MANMLH�UNL M)
17— 7 �!— j�� Board of Health, 1 , MA.
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r A1/.SLCAYI N FOR DI P®SAL SYSTEM CONSTRUCTION PERMIT
(• ��
plicatiori for a Permit to Construct
) Repair( ) Upgrade( ) Abandon( ete System O Individual Components
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Location Ozne- G p
Owner's Name
Map/Parcel# �U �]
Addressao A) Hco'/)':�-& Cj, ( o--� v2f'
Lot#
Telephone#
Installer's Name �K �n"fi2�
Designer's Name` , J m �
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Address Ls is x(41 o �t - rJ SEQ r d a� 3
Telephone# 3--J3 -33,5- 5 99-3
5-549'
Telephone# ,fig -g96 -(Ob
Type of Building ( L0-Cip
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date
�_T% c 6 ((e N(lumber of sheets
Title I / 1 - '�ao- ' oo C� `- Z .lr w o i eS
Description of Soil (s) '_'
Soil Evaluator Form No. Name of Soil Evaluator
OF REPAIRS OR
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided . gpd
Revision Date
Date of Evaluation /O
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3) rcc eS,S op u -Lm L, , ri . SPo t� O hsen btA O n �n r� I
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 system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections S EZ l/ % -,561-6 DK.
No. Q M —0 3-791 , .
COMMONWFA-LT14 OF MASSACHUSETTS
Board of Health,yQxA , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 3-GSmplete System
The undersigned hereby certify that the Sewage Disposal System; Constructedepaired ( ), Upgraded ( ), Abandoned ( )
by Tri tl - n.. C � "`� r4 c (( �,
at 42cl mY
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the
application No. dated 4- —4( Approved Design Flow
Installer -k-) r--- 1 '
Designer`; ,' �� a ' �!, c{ CI < Inspector:
(gpd)
design plans/as-built plans relating to
Date: T%
The issuance of this permif shall not be construed as a guarante at the system will function as designed.
Board of Health, Oy , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE Ci I o a
. 1035 :
Permission is hereby granted to; ConstructO Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at— Ll !' ✓ r G O � as described in the application for
-
Disposal System Construction Permit No. 117-17, �, dated 4 --� r- ,`
Provided: Construction shall be completed within tis oft{ e date of this permiAa N1 local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date /Board of Health