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OMMONWEALTH OF MASSACHUSETTS
f� MA.
y� „� Board o Health, ,APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMII
FEE
Application for Permit to Construct( ) Repair( ) Upgrad Abandon( ) - Complete System ❑ Individual Components
Location i -H o✓f,'(/ e
Owner's Name
Map/Parcel# �t.� �s
Address 0�`Jk jj ( l�+-►e1 �L^
Lot#
Telephone#
Installer's Name k h L� W"J�7 � p y f F}
Designer's Name fc (-4 4 14 44-_' fy7
Address a h �
Address
Telephone# S
Telephone# -5,G 14 _6
Type of Building .ii✓ Lot Size 0? sq. ft.
Dwelling - No. of Bedrooms U Garbage grinder N10
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow _ Design flow provided 3% gpd
Plait: Date _(�!1//(� 1�7 Number of sheets h Revision Date
Title V ' 1 f
Description ofSoil (s) Soil 4=�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agree o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n o�pla the tem ' r 'on until a Certificate of Compliance has been issued by the Board of health.
Signed r Date :F7 �
Inspections��
,,�� 06
No. hC _ COMMONWEALTHt.�'.. FEE
Board of Health;.; r MA.
CERTIFICATE.OF COMPLIANCE
Description of Work: ❑ Individual Component(s) s®''Goxnplete System ,
The undersigned hereby certify that the Sewage Di nsal System Constructed ( ), Repaired ( ), Upgraded 41-r,'Abandoned ( )
at 1T M9o i/`
has been installed in accordance with the peovisiRn of 0 CMR 15.00 (Title 5) a e a roved design plans/as-built plans relating to -
application No. 7-- "'T, dated ~-�/ �� Approved,,Design Flow? (gpd)
Installer C - C,.1 r _
Designer: P U KI f ` N o R Al S/ AWZ,6spector,�fP'� /.'�'1�� ` 0 Date: �/ � /' " /-i
The issuance of this permit shall not be construed as a guaroaffee that the system will functionas designed.
7 7.44-- COMMONWEALTH OF MASSACHUSETTS
�f 5 Board (f Health, A (M4 MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
at If M gol1� S Uy�t IVe q itr
Disposal System Construction Permit No. _
FEE_`O
Repair( ) Upgrade (Abandon ( ) an individual sewage disposal system
go
dated r%
as described in the application for
i
Provided: Construction shall be completed within three years of the date of this per All local
,condi ns must be met.
Form 1255 Rev. 5/96 A.M.Sulkin Co. Chadeslown MA to / Board of Health