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FEE 10 , 00
COMMONWEALTH Of MASSACHUSETTS C,014k �
Board of Health, PE'�LTN D28 � ,
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�WLICiAlTI®N FOR DISPOW MMYRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon() - !'Complete System ❑ Individual Components
Location aci OrCk1A '
Owner's Name
Map/Parcel# 9 b l/�ce 97
Address a j <)(,C(, ik 1Aq c
Lot# I !
Telephone#
Installer's Namei, j ��� COR
Designer's Name V
AddressP- 6aX C-71
Addre3 fox ')bY Dun ��
.one#
Telephone# 5z'T,'T- 9
Teleph3 (� CC
Type of Building I 6\.k� ee rr Lot Size I l 1`r/) sq. ft.
Dwelling - No. of Bedrooms ti -p— IL—Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures ' f
Design Flow (min. required) gpd Calculated design flow LIS 7 Design flow provided gpd
Plan: Date 1" b - 17 Number of sheets i Revision Date
Title Sik 0.
Description of Soil(s) 'neaW f t ws,
Soil Evaluator Form No. Name of Soil Evaluator ZM-F3 Mddh'Date of Evaluation
DESCRIPTION O REPAIRS O TERATIONS / eAJ SL4 i jL.Z � �rl � 4 41 -o 5b3 (::F �/�I C zS
S 1
The undersigned agree tallthe e, e described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no place system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed / Date `— '16-17
Q�
Inspections 1 S -e C:)jj T—A
0
No. i ` FEE
COMMONWEALTH OF MASSACHUSETTS
lBoard of Health, VIN M .e ,1-.. MA.�, !J
CERTIFICATE Of COMPLIANCE t ,
Description of Work: ❑ Individual Component(s) �Komplete System
i( -
UnedThe undersigned herebycertify that the Sewage Disposal System; Constructed (�}, Repaired(,. Up ad Abn
_
by:
at �%
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved
application No. dated Approved Design Flow (gpd)
Installer t �'
Designer:�,���//ti
The issuance of this permit shall
No.
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— A , vim, v - , ".. —, , ....--r.,-..�y.. -
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Inspector: `` Date:
not be)construed as a guarantee that th system will function as designed.
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6 L V t L-6 C Y Q FEE J` ^y
C®MM®NW LT14 OF MASSACHUSETTS ( h
Board of Health, IlArm ,,'1 , MA.
DISPOSAL SYSTEM.CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at Q r") f r( TT as described in the application for
Disposal System Construction Permit No:, dated
Provided: Construction shall be completed within thre o `ed& date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date_" Board of Health r /�K
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