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COMMONWEALTH OF MASSACHUSETTS ods
Board of Health, MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location i Si L
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name i �j � �
Designer's Name 6Uj &f 11leerl VkA
Address 3&
u-5iw
Address ei-�Lttu+ N '
Telephone# 015010 - 11
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)
gpd Calculated design flow
Number of sheets
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS C, iekytc-
Lot Size �� sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Design How provided, _ gpd
Revision Date
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 as to not lace the system in operation until a Certificate roof Com fiance has been issued by the Board of Health.
Signed Date V
a
Inspections
COMMONWEALTH OF MASSACHUSETTS
FEE 55,60. .., .>
Board of Health, YAama 1 , MA.
CERTIFICATE Off' COMPLIANCE (111 -Kir? 17 �;, , �.�% ���' �
Description of Work: ❑ Individual Component(s) 0 Complete System1 � ' ,, 4e
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade), Abandoned
by:
at
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. r ✓'P & , dated 2!f� - �1 " f 7. Approved Design Flow.;/(gpd)
Installer 0 (w n /-,p rl,1,4 1�4 0 C /` k /,, 1, k—, -Th" o M V7V (_f.uvAl-C _ tr2//
` /r'
Designer: ,,1ecjGjfuw ,1D Inspector: ! Date; i
The issuance of this permit shah not be cons rued as a guaran -'that the system will function as designed.
IWEV
f FEE,
Board of Health, VAaM0j)MAn1 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; PConstruct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. /Z-- P 4 , dated ,_-f-a
Provided: Construction shall be completed within tja�""ofhe date of this permit. All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadeslown, MA Date r Board of Health r _� � / ,+ o° '15f