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No. Ot WDC D - 4 23G -ries W*A 13 I- DI- k 1-7-60<,1160
J �-1 ®MMONWEA LTH Of MASSACHUSETTS
L_ e �L Board of Health, MA.
Pq47A OL ATION FOR. DISPOSAL SYSTEM CONSTRUCTI
Application for a Permit to Construct Repair( ) Upgrade( Abandon( Kcomplete Systen..
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FEE .�//''ii
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RECEIVED
MI , n !017
PERMIT
HEALTH DEPT.
Individual Comnonents
Location /a /—O/t��A 1"�eQ RO BEST Owner's NameCHA""'-mss `7`
Map/Parcel# / 7/-7-6 Address
Lot# a c/my Telephone#JO3 �'S6 — 0736
Installer's Name Designer's Name
Address 477 rOCOA4 �3��k /Z�b Address Donald W. Monceviez, P.E
,a�s7' aiei+lcsv�rH !Vl
d::L673 Civil Engineer
Telephone# r08 '77,9--044Lf Telephone# 40 Pond Street
West Dennis, MA 02670
Type of Building ,,�'S�,o��T'��l- Lot Size Ag. -g6)04-_ sq. ft.
Dwelling - No. of Bedrooms .3 f%Lr51 e-- 1 Ave 3 Garbage grinder No
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow Design flow provided � gpd
Plan: Date MAX3404 a.D%- Number of sheets % Revision Date
Title r� /�i'�rOl�®Si�� .Si�Nl7"R�'cy � 57'C�/�f 0PQRAD,65WMIN6 i(fa, /
Description of Soil (s) C✓� L A
Soil Evaluator Form No. Name of Soil v tiatVV 6N Date of Evaluation �}
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 e7 in op ation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 0 20!
tions _ -
No. ' `i �- Q EE C
C1W
COMMONWEALTH OF MASSA U TT� -d
"oard of Health, __- ��' , MA.
CERTIFICATE Off'" COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed, Repaired ( ), Upgraded (, Abandoned( }
by: "B . C, 14.r C-0 QW N -,,lr�- -
at 1.. /�� '96AP U eycr >4�Iill
has been installed in accor ance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated f. Approved Design Flow _3!5:7 (gpd)
Installer
Designer: ]Art/e-91ZIC Inspector: Date; -/
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
No. bo 4 Dc ("`t z 3 0 j . C . i - o FEE
COMMONWEALTH OF MASSACHUSETTS LV
Board of Health, NUMf11 MAr- MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) UpgradeO Abandon( ) an individual sewage disposal system
at / kVO4 ®02 (XJ4i'A�/1f�t��'%3'�f4 as described in the application for
Disposal System Construction Permit No. dated��`
Provided: Construction shall be completed within rs W1e date of this permit. All local c editions must be met.
Form 1255 Rev.. 5/96 A.M. Sulkin Co. Chadesf P- MA Date "e� r' i� Board of Health 2 . t:et�r " 4-0—�
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