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No.
FEE'^�vV
CrONWEALTH Off` MASSACHUSETTS 2a yS
Board of Health, YQ (M aQ 4 MA.
FOR a TON PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade V Abandon( ❑ Complete System )WIndividual Components
Location 'Z.°i --r,
Owner's Name
Map/Parcel# S - ZZ
Address �e �TC'�O►� 7��CL "A,uj-,
Lot# L ( Z
Telephone#
Installer's Name aily %'
Designer's,. Name U -b J C
Address
Address
Telephone# "774/ Od
Telephone# a
Type of Building Z� S Ce Y� t a � Lot Size � t 0-0 1 -k-/- sq. ft.
Dwelling - No. of Bedrooms ?J Garbage grinder ( )
Other -Type of Building %Jet A- No. of persons Showers O,'Cafeteria
Other Fixtures _/�%/ /-
Design Flow (min. required) Z-gd
gpd Calculated design flow '33 i CJ Design flow provided 7v33 gpd
Plan: Date 4? I ZZl 1 /� Number of sheets 1 _ Revision ate
Title�,d® l &A0 c- �c !C -e-m OW& C�.()l�( �ti� �i �C�S(7✓� AyA W/ Larf-�
Description of Soil (s) O- 7 �- J l -7-13 0 LIS 0-3Z 13 LS :3Z --7-Z,<- A -'C
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 12-e k"r) 6X i S
The undersi d ees to install` thea described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further a e not to plape th t in operation until a Certificate of mp 'ance has been issued by the Board of Health.
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XSigned Dat77
e—
MA
Nu. COMMONWEALT11',OF MASSAC STTS�,�.
Board of Health, AL4. 1)
CERTIFICATE OV'COMPLIANCE 011�-
Description of Work:, Individual Components)Co lute S �s^te
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded U,>A'gandoned ( )
by l
has been installed in accor a c„e,,with the provisions of 310 CMR 15.00 (Title 5) ai
application No. + : f dated % ` d f Approved Design Flow
design plans/as-built plans relating to
Installer
Designer:. t"� 0° ( !` Inspector: >.° d Date: Z7
The issuance of this permit shall not be construed as a guaran at the system will function as designed.
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No. 2 A- �_ 1 � �` C"J � o, �� ! (�.) :`J.� �-�i '� � � FEE
COMMONWEALTH % MASSACHUSETTS ���`g-
Board of Health, '�"fet C w% o 1 i �'\ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission ishereby granted to; Construct( ) Repair( .) Upgrade (A, Abandon ( ) an individual, sewage disposal system
at -9 j -e Z'e.'f S 0 ,x ?\ V- V-3 as described in the application for
Disposal System Construction Permit No. -- IT ti , dated 7'j -l-`- / 7
Provided: Construction shall be completed within t441111r of�the date of this pert 't. All local conditions must be met.
--� --
Form 1255 Rev. 5/96 A.M. Sulkin Co. Cha�estown, MA }� /Date Board of H alth r
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