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�rFEE
COMMONWEALTH OF MA-SSAC14USETTS dt -,
f� Board of Health, `y„V MA.
APPLICATION FOR. DISPOSAL SYSTEM CONSTR PEN IT
Application for a Permit to Construct( ) Repair(vY"'UpgradeO Abandon( ❑ Complete System Vlndividual Components
Location 3 �� 1� r r
Owner's Name
Map/Parcel#
Address ` ,, eA2
Lot# e
Telephone#
Installer's Name .�x�
Designer's Name
Address Fo �����` jnLNvA
Address
Telephone# "�Q
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Lot SizeQ3, 6-) f sq. ft.
Garbage grinder( )
Other -Type of Building _ No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided Ll e' jgpd
Plan: Date Y/ �n f 10 Number of sheets 1 Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator ug; 4 f, Date of Evaluation
DESCRIPTION OF REPAIRS' OR ALTERATIONS yA yD5
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ��� i Date Y
Inspections
No.�tJ�
Description of Work;
FEE 00
COMM'ONWEALT14 OF MASSAC14USETTS !4 4 - i-� , ?
Board of Health, {ib g Dd p_�T , MA.
CERTIFICATE 'U�COMPLlli 1 NCE
t�'lndividual Component(s) ❑ Complete System
),Repaired Upgraded-( ),Abandoned(
The undersigned hereby certify that the Sewage Disposal System; Constructed (
by:
at
has been installed in a co ante with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated �r� % Approved Design Flo (gpd)
Installer A—r2-1
Designer: +j�I/./I%= Inspector: Date:r-
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