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17 // COMMONWEALTH Of MAS BCH ���T � CA0 8�3
Board of Health, ��� , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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AP` lication for Permit to Construct() Repair UpgradAbandon(❑Complete System nvidual Components
` Location
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Owner's Nam
Map/Parcel#
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Address , �j-
Lot#
Telephone#
Installer's Name+-"
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Designer's Name/'3s
Addressr
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Address
/
Telephone#
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Telephone.# m -
Type of Building a
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Lot Size
sq. ft.
_ Garbage grinder ( }
Showers ( ), Cafeteria ( }
gpd Calculated design flow Design flow provided
Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS
The undersignedigVE& to in
further agrees, o n o lace
Signed
Inspections
Date of Evaluation
gpd
No. (���-�1 % •.. L { t Ko
Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
until a Certificate of Compliance has been issued by the Board of Health.
Date � , f
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COMMONWEALTH OF MASSACHUSETLS-- C^
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Board of Health, i
CERTIFICATE 0, F COMPLIANCE /�,`���r�
Description of Work: individual Component(s) ❑ Complete Systemy
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The undArsi ized,�ereb certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Uttpgraded), Abandoned(f
by:%
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and th pproved design plans/as-built plans relating to
application No. a /, dated Approved Design Flow (gpd)
Installer LG)
Designer:ftl L W . Inspector: 6.". Date: ' 1
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The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
LAI�aj.v FEES
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COMMONWEALTH- OF MASSACHUSETTS CA5tj (2E7..
Board of Health, Y%{vl AL1., MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebynted to; Construct( ) Repair( ) Upgrade °) Abandon( ) an individual sewage disposal system
at - 1 '- as described in the application for
Disposal System Construction Permit No. r,—�, dated C,`-'�
Provided: Construction shall be completed within three years of the date of this permit. All local condi 'ons must be met.
Form 1255' Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date --//—Board '�Board of Health �r