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No. A V "� � i ! - FEE510
C®MM®NW 669A A"&�AASETTS l�
Board of Hea 146 ROUTE 28 MA.
_ _ _ ,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete' System ❑ Individual Components
Location 3
7 Lq 11--1
Ti -,e " ,
Owner's Name
%VG/^Nq P4-1 5 C`j L/
Map/Parcel#
Address
L�j & -C eel \e 0'
Lot#
Telephone#
3 - 7 3 C,
Installer's Name
' ✓ I �7
f
�C Designer's Name
Address a-3
�'n
V
Address
Telephone# 3
K77 I/
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)
P-
Soil Evaluator Form No.
D$SCRI$TION OF
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
The and igned agrees t ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a es to n to 1 e in�operation until a Certificate of Compliance has been issued by the Board of Health.
Signed /Date �� l,V ^ 03
Inspections
No. 0-37 Z-- COMMONWEALTH Of MASSAC14USETTS FEE
. Board of Health, MA.
CERTIFICZ6F COMPLI'ANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
at —\ So SA rLM Sy �.�\
has been installed �in, accordance with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. "✓'Jn "i 7Z -dated /6 Approved Design Flow (gpd)
Installer l L! i
r
Designer: Inspector: _1.� / Date:
The issuance of this permit shall not be construed as a guarantee thIt the system will function as designed. _.--
No. i% 7 FEE
/ Board of Health, MA.
o�1 DISPOSAL SYST ONSTRUCTION PERMIT
Permission is hereby gra ted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at e d) N O / i i as described in the application for
Disposal System Construction Permit No /9 3 w dated 104 r�
Provided: Construction shall be completed withiinn� t�>�@@,. s of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date e/ ' / '1-3 Board of Health 6.X