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Board of Health, V/ 41W O (�j�- MA.
APPLICATION FOR DISPOSAL SYSTEM ST CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑ Complete System fkIndividual Components
Location
Qf3 �-�
Owner's Name Oig*-P . d,7 MtTv e- `&>eg 64C
Map/Parcel#
Mt3LO .31
Address Lf j.�_ R7 g WE$.r
Lot#
Telephone#
Installer's Name `4M z) f p6 Cmrc-A: &js
Designer's Name N lA
Address 153
Cog(*
Address
Telephone#
5UZ 77 >
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms I Garbage grinder ( )
Other -Type of Building No. ofersons Showers
p O,Cafeteria, ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow Design flow provided
Number of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS RCP 4ACZ) r Oy K S V5reE)a *--(p 41bll
:;r"smc.l_ IUc@u; t4-;LI) -40y,
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 system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed C -C Date -� l
Inspections
d4 02-3 3
COMMONWEALTH OF MASSACUUS
Board of Health, , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired K, Upgraded( ), Abandoned ( )
by: 4peco l7E agl:5
at 415a RnLrnig aR
has been installed in accord ce withthe rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ,� dated �. Approved Design Flow (gpd)
Installer e4A'?e7w lbw =j7�v i SSC 1� Lend (-A Pc. _
Designer: Inspector:
Inspector:
The issuance of this permit shall not be construed as a guap
Date:
�e that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health,paj} 07T• , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
FEE
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Permission is hereby granted to; Construct( ) Repair(K Upgrade( ) Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No., dated�f
Provided: Construction shall be completed within as �of the date of this per t. All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadesfown, MA Date -3-0/7, w ' Board of Health '�