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COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y MD0T1+ , MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct(/Repair( ) Upgrade( ) Abandon( ) - ffComplete System ❑ Individual Components
Location
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Owner's Name
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Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
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Designer's Name u
Address
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Address.y
Telephone#
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Telephone
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Type of Building />°�%� Lot Size/� / 72 sq. ft.
Dwelling - No. of Bedrooms /�03 Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) /1 gpd Calculated design flow Design flow provided gpd
Plan: Date I Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No,
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a e not t lac th tem in operation until a Certificate og om fiance has been issued by the Board of Health.
Signed Date �a
Inspections nn
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fY COMMONWEALTH Of MASSAC14USETTS$`'� /6-°��� a45 1+
Description of Work:
The undi
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has been
Board of Health, 0114
CERTIFICATE Of COMPLIANCE �--=5—��d�� { �-
❑ Individual Components) Complete System
by certify that the Sewage Disposal System; Constructed, (q ), Repaired ( ), Upgraded ( ), Abandoned ( )
AledfM-r ' d ticc''witlf &e 1S'ro% io s of 3 0 CMR 15.00 (Title 5) an roved design plans/as-built plans relating to
dated 4' � -/� Approved Design Flow _ (gpd)
" Installer & i
rV •.��'f/erns ector: Date:
Designer: �' p -
The issuance of this permit shall•not be construed as a guars; that the system will function as designed.
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Al - �5_ __5 COMMONWEALT14 Of MASSACHUSETTS
P. ,r- 3A 4, 51'7,
Board of Health, yM?_M0U1- i , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Constructy )
Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within tlfe&+9,rs�o}f 1t�he date of this permit...- l local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date j�$oard of Heal
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