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COIMONWF-A1LT14 Of MASS CHUSETTS
Board of Health, Y/AeM0 QTR , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTIP1J t&-VPER,�M
Application for Permit to Construct( ) Repair( ) Upgrade-)bandonO - ❑ Complete System"tnndividual Components
Location
in cQo S 5 '
Owner's Name / 5
Map/Parcel#
-
Address NO,p C 0 Y1
Lot#
Telephone#
Installer's Name
Designer's Name Me 16W -t
Address 1140
Address & el 1
Telephone#(p
�0
Telephone# 50 3(� 0-� -331 f
Type of Building QV ,3 Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) .33D gpd Calculated design flow Design flow provided .3-i2 + gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to inst the bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no o lace s tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed L�-� Date S -
No. a%{ 1/ C "1 / "`'t { { ? CM NW1f`AL14 Of MASSACHUSETTS FEE
f Board of Health,fD1n , Am A.
CERTIFICATE Oilm C0MPL,IA�Tl CE
w-;
Description of Work; P.Igidividual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired graded ( ), Abandoned ( )
by:` + c
at u /go
has been installed in accorg4an e with the provisions of 310 CMR 15.00 (Title 5)
application No. JJ , // dated . Approved Design Flow
Installer od hPt4 a7,h V=Jti-6wl*
the approved design plans/as-built plans relating to
Designer: -_Talc Inspector: _.,Date;
The issuance permit shall not be construed as a guarail ee that the system will function as designed.
�p,,p� � if
No.Qt3d�-=1 % ^ ! ( �Q� Sl 1'^ FEE�,1
Board of Health, Vg!paM6k)'1" A , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(/ Upgrade( ) Abandon( ) an individual sewage disposal system
at �f'7 1 r'� as described in the application for
Disposal System Construction Permit No. dated, . %
Provided: Construction shall be completed within 4W__4A the of this emit. All loca d tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslodn, MA Date r �� Zoard of Health