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COMMONWEALTH OF MASSAC14USETTS
Board of Health, y/�(�r�lOU—r-ki , MA.��-�
APPLICATION FOR 7,,,PPOSAL
SYSTECONSTRUCTION PERMIT
lication for a Permit to Construct ORe airae Abandon ❑ Complete System MIndividualCo
m onents
Location
Owner's Name
Map/Parcel#7
T
Address
J ', h t
Lot#
Telephone#
• J K- 5 3
Installer's Name
, w\ ,
Designer's Name
Address '3 *3
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Address 1 1
,�
Telephone#56
_.
f
Telephone#
Tom=
Type of Building _
Dwelling - No. of Bedrooms
Other Type of Building
Other Fixtures
No. of persons
Lot Size
sq. ft.
_ Garbage grinder( }
Showers ( ), Cafeteria
Design Flow(min. equired) 2-j— 0 gpd Calculated design flow Design flow provided _ gpd
Plait: Date IgNumber of sheets Revision Date
Title
Description of soil (s)
Soil Evaluator Form No. Name of Soil Evaluator !` Date of Evaluation
E PTION F PAIRS OR ALTERATIONS 0 1.5 t U� V O
D C RI�C'i4 W
The uno
further
XSigned
Inspections
stall the above described Individual Sewage Dispo al ystem in accordance with the provisions of TITLE 5 and
the system in operation until a Certificateo C rl
ce has been issued by the Board of Health.
Date
C®I�l MON�LT14®E MASSACHUS ENk/ �}1��
t7 /0 2 at-ock -- 1owt2-
Board of Health, J S� MA. W`
CERTIFICATE OF COMPLIANCE
Description of Work: 2>dividual Component(s) ❑ Complete System ,�`�
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), RepairedX1
); Upgraded ( ), Abandoned ( )
by ) !� `'
at Li-)
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /7--/ 0Z dated %f % . Approved Design Flow — (gpd)
Installer
Designer: "".... Inspector: Date:
The issuance of this permit shall not be construed as a guarVt a that the system will function as designed.
No. I� f) 44 " ^ C ...1 T - `� `i � (� t ti� FEE S 00
COMMONWFALT14®F MASSACHUSETTS CIL L/r z.
Board of Health,O �) 1 I -a MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system
at L4'? _ 1( rc A J i,--s)C% as described in the application for
Disposal System Construction Permit No. ' 40 , dated _ % r / .
Provided: Construction shall be completed within three years of the date of this p�erpi ,y All local con 'tions must be met.
-7 Board of Health
Form 1255 Rev. 5/96 A.M.Bulkcn Co. Chadestmvn, MA Date
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