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COMMONWEALT14 OF MASSACHUSETTS
¶ Ttt �T Board of Health, ' MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade V) Abandon( - ❑ Complete System ❑ Individual Components
Location—
Owner's Name l l
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name.'
Designer's Name
Address !�
1
/ %// , `
Address
Telephone#l'1��^�
Telephone#j
Type of Building tda 9 ,. Lot Size sq. ft.
Dwelling -No. of Bedrooms k:5� 2- 1 `may �P'7 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) �� gpd Calculated design flow�G Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
Theundersi agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further at
ee o of t 1 th&steni in operation until a Certificate oS Compliance. has been issued by the Board of Health.
Signed Date _
Inspections
No. ??6 44 IDC "' 1 "2 -3 5 3 7 FEr i (J QU
COMMONWEA-LTH OF MASSACHUSETTS
Board of Health, YAPAbkma , MA. �.
t
CERTIFICATE Of COMPLIANCE
Description of Work; ❑ Individual Component(s) 4,Kplete System
The undeysi ed Wreb certify that the Sewage Disposal System; Constructed , Repaired ( ), Upgraded ), Abandoned O
by: / s
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
application No. 17
—f dated 4�. Approved Design Flow (gpd)
Installer t) e, t r -7
Designer: � C 6(c 0 t12 Inspector: Dater 5-1 _,��d
The issuance of this permit shall not be construed as a guar " ee that the system will f ction as designed.
No. b (,, H i � C - S -% —35 3 G= FEE 0
7- COMMONWEALTH Of MASSAC14USETTS
fHealth, J- MA.
Board o ,
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby anted to; Con tract( ) Repair( ) Upgraded/) Abandon( ) an individual sewage disposal system
at v=''. as described in the application for
Disposal System Construction Permit No. I dated 1,9,'z7
Provided: Construction shall be completed wi,thinq�M`�,f the date of this pe - 't All local con 'tions must be met.
Form 1255 Rev... 5/96 A.M. Sulkin Co. Chadeslown, MA Date I) �� Board of Health