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COMMONWEALTH Of MASSACHUSETTS
FEE
Board of Health, y y F'1 , MA.
APPLICATION FOP, DISPOSAL SYSTLM CO STRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad AbaO ndon- Complete System O Individual Components
Location 9122i
Owner's Name
L& -+ AM dtuj r e( 10
Map/Parcel# Z(o
Address Va
Lot#
Telephone#
Installer's Name
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Designer's Name M
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Address
Address
M I iiA).
Telephone#' ma uo
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 rr����
Design Flow (min. required) CJ1/ gpd Calculated design flow 0 Design flow. provided gpd
Plan Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator 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 afire to not to place the system in operation until a Certificate of Complilnce has been issued by the Board of Health.
Signed AiWu , Date
Inspections
No.R J , %;7— er4 % FEE
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MMMONWEALTH OF MASSACHUSETT "x.06,-�7
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Q-C-6.�plete System
The undersigned hereby cer
ereb `certhat the Sewage Disposal System; Constructed ( ), Repaired { ), Upgraded andoned ( )
at
has been 'installed in accor d cwith the provisions of 310 CMR 15.00 (Title 5) and the aoproved design plans/as-built, plans relating to
application/No. -- rf— dated _ Approved Design Flow..::;f�(gpd)
Installer An /1) V-11 /
Designer:
The issuance thispermit' Inspector: � _ Date:
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sh not be cons a gu ee that the system will function as designed.
No. j� J ` !� ?�C FEE
Board (f Health, �AQNO, M�, MA.
DISPOSAL SYSTEM CON,$TRUCTION PERMIT
Permission is herebygrantedto; Construct( ) Repair( ) Upgrade (,< Abandon( ) an individual sewage disposal system
at40 6 as described in the application for
Disposal System Construction ermit No, , dated
Provided: Construction shall be completed withi rs of5e date of this perm All local cog4itions must be met.
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Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadestavn, MA Date i % Board of Health /