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COMMONWEALTH Of MASSACHUSETTS C"465
Board of Health, _YARII0 U� , MA.IF
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j&eAt,-APPKICATION FOR DISPOSAL Sy TEM CONSTPUCTfON PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad Abandon( ) - ❑ Complete System •Individual Components
Location 72 A -0:F-,"5SF—
Owner's Name �'f��U�--��/lJA$/,4i"�Q�l)eAft
Map/Parcel# rn,4t q jPt4e4ct° •*- /
Address 4VW ZZ;
Lot# z,
Telephone# � jQr- �, j ejr-'srSl,6
Installer's Nam �'�� v/A�,lipIWA! (J%�J�
Designer's Name jr/
Address X 2 -0 -sr ,e -- 10,4
Address �W llo
Telephone# �Jg- �- l ;" 'Ltd
Telephone#
Type of Building 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) gpd Calculated design flow k6O— Design flow provided gpd
Plan: Date 6 9e Number of sheets -fl Revision Date
Title // �7V-4Ti,Clf7
Description of Soil (s) �i4 !. .�
Soil Evaluator Form No. A13-971 Name of Soil Evaluator'X,4!y ,e0_A/t / Date of Evaluation u�11*711`7
DESCRIPTION OF REPAIRS OR ALTERATIONS 37067 -Alk -- N P40 } b M12 of kA be Q 14Ajd
401 <- le- 4 Lobo f goFcL.iE O1Dt'Tl�-!,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees td iAot t ace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed/`'�� i Date 6 /a 7 la O W
Inspections
No.6 o iA vc 1 1 "l"",,,? /, A Gr.4 f
MASSA
COMMONWEALTH OF
Board o Health M
CERTIFICATE Of C®MPLIANC ,-7- :?-4 - ,
Description of Work: ?(Individual Component(s) ❑ Complete System > ���CaThe undersigned herebycertat the Sewage Disposal System; Constructed Repaired pgrdedYo ne�di �
()
by: , LL C A F F- t v 1 °R. o p wr r-- &7rA L
at 7Z C"4.OTAZA-1 E,65;545. 1ZC+4 D
a
has been installed in accordapce with the provi ions of 310 CMR 15.00 (Title 5) and theF approved design plans/as-built plans relating to
application No. 1 �► dated ` / Approved Design Flow _, (gpd)
Installer
Designer: WWW C49r;/%nspector:
The issuance of this permit shall not be construed as a guara
No. _ " `t v / „� &L- t�-•1�r L'
COM ONWEA .T14®f MASSACHUSETTS
Date:
fined.
Board of Health, A(ZM 0 l - , MA.
DISPOSAL SYSTEM CONS=TRUCTION PERMIT
FEE�T�);
t
Permission is hereby granted to; Construct( ) Repair (>q Upgrade( ) Abandon( ) an individual sewage disposal system
at r 4--2407- at5. a' ,410 as described in the application for
Disposal System Construction Permit No. �� dated 0 1 / `7
Provided: Construction shall be completed within - f the date of this p it All local c ditions must be met.
7
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date Board of Health