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No. "� j FEE
�r A A -P COMMONWEALTH Of MASS ACHUSETTS t6
%v of wew Board ofHealthYARMOUTH HEALTH DEM.
1146 ROAPPLICATION FOR T
UK"RUCTION PERMIT
Application for a Permit to Construct(&rRepair( ) Upgrade( ) Abandon( ) - Uomplete System ❑ Individual Components
Location (14 4 a, ; U
Owner's Name
Map/Parcel# /00 2
Address
Lot#
i
Telephone#
Installer's Name �•
Designer's Name • t
Address CIV2 W.- V,
Address
Telephone# S d � _
Telephone#
Type of Building [lrcr, fry ' Lot Size J.r 2 y9 sq. ft.
Dwelling - No. of Bedrooms 'Z Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) J/10 gpd Calculated design flow ZZ -0
Plan: Date G" 3— pp Number of sheets
Title
Description of Soils) _
Soil Evaluator Form No.
Design flow provided 3 Vo— gpd
Revision Date
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS U-) 99�jI „,�,,/5� �"� �"� 1411a°i 1
S!10J 6,04tdd s 04gg 700 4,A) Av--/o�..)
1/0'�; A
Siegmund Environmental Services, Inc.
49 Pavilion Avenue Providence; RI 02905 U.S.A.
The undersigned agrees to install the above described Individual Sewage Disposal Sy,,
further agrees to not to place Qhe syste in operation until a Certificate of Compliar SS
r
Signed Date C
Hollister Stephen J. Siegmund
Inspections� %� � � �
te1401-785-0130 xii401-316-7877 f.401-785-31 0
Affiliated Qffices in New England the Caribbean & Central Europe
www.siegmundgroup.com hollister@siegmundgroup.com
No. FEE
COOSTH Off' MASSACH SETTS' S!lszq �,,� �I CJC�
G {gra �rp�
Board of Health, -U yt.)('
CERTIFICATE'OF COMPLIANCE
Description of Work: ❑ Individual Component(s) 16YComplete System
The undersigned hereby ceyrti�fy that the Sewage Disposal System; Constructed (fo< Repaired ( ), Upgraded ( ), Abandoned ( )
by:,. C" K,►J�
at 4.. LL �t.ar-Z,1' /,c� S. 11
has been installed in accordance with the rovisio s of 3.,10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �� dated 64 4. -'Approved Design Flow Yo (gpd)
Installer 47
Designer: � A fn (� �5 a4 &47- l �,Jc inspector: Date: 7'40 2
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No. _ �' FEE AP 0. 4y �
COMMONWEALTH OF MASSACHUSETTS,
1
Board of Health, AAkk V1N_0t . MA
DISPOSAL S' EM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( pair( ) Upgrade( ) . Abandon( ) an individual sewage disposal system
at Ad as described in the application for
Disposal System Construction Permit No. "", dated
Provided: Construction shall be completed within' of�`alate of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA DateZQ2_ Z -Board of 6alth — 0'e/� L