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XV
No. c
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
APPLICATION FOR SP®SAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete SystemAIndividual Components
Location
i,S 1
Owner's Name a ri
Map/Parcel#
DSB� 23�
I
Address J SSL'f t�� k -
Lot#
Telephone#
Installer's Name
o -e vt, vu d &4
Designer's Name
Address
Q f S15M
Address
Telephone#
3
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
9
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees lace em in opera ' n until a Certificate of Co p i ce h been issued by the Board of Health.
Signed ~� Date
Inspections
FEE 00
No. ��
M COMMONWEALTH
' ®F MASSACHUSETTS � �
Board of Health, 5/ 0 Mf 111,M.
CERTIFICATE Of COMPLIANCE
Description of Work:Individual Component(s) ElComplete System
." .'
The undersigned here y certify that the Sewage Disposal System; Constructed (Repaired ( ), Upgraded (, Abandoned O
by:
at
has been installed in acco ace with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built-plans relating, to
application No. Y dated �. ,?,)proved Design Flow ^'" (gpd)
Installer
Designer: Inspector:f !_ &-: Date:
� r
The issuance of this permit shall not be construed as a guaraeSde that the system will function as designed.
No. (� C1(i A C c to %� t''��^ FEE
~ . ' COMMONWE-ALT14®IE MASSACHUSETTS ��� 415
Board of Health, _VA" of JD4
DISPOSAL SYSTEM CONSTRUCTION PERMIT
I
Permission is hereby grapted to; Construct( ) JRepair U rade( ) Abandon( ) an individual sewage -disposal systemat ' !�-�� ' `u /` .. as_described<in the application for
Disposal System Construction Permit iso.- , dated 'r
Provided: Construction shall be completed within,tllCars of thdate of this permit:,. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown MA Date ` r f tsoard of Health ,' J J