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No. O pC-1(6 013 !; O..� `SIO FEECOMMONWEALTH Of MASSACHUSETTS d4-17�7
Board of Health, )619Md Vn± , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT
Application fora Permit to Construct( ) Repair( ) Upgrade�bandon( ) - '"Implete System 0 Individual Components
Location &Q
Type
S-PAITPOW
Owner's Name �IIah ewe e
Map/Parcel#
er�9
Address �7® J' o^Acfy04Y/
Lot#
Telephone#
Installer's Name
Designer's Name �dt .07,15
Address �'/�
it e dv„y /! y� .4e ye f
Address V44
Telephone#
Y—e J", f d
Telephone# '770e ZaF -2a-?f—
2a-?f—
Type of Building e-1 Lot Size Ao, � sq. ft.
Dwelling - No. of Bedrooms ..h Garbage grinder { )
Other Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow 3 76? Design flow provided c�' 9 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t of top ce%e ate m operation until a Certificate of C mpli nce has been issued by the Board of Health.
Signed --7 Date
Inspections
W
No. 16CAVC— 4 - � ,"� FEE .,-t.- . 00
Board of Health, �T , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) 2<omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded;,) -;'Abandoned ( )
by: ✓r (s 4W 144,01-- 1--'e
-
at AAP -21 r C.✓X V
has been installed in accordan e with the provisions of 310 CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to
application No. dated Approved Design Flow _ (bpd)
Installer
Designer
Date: ! iAGm
The issuance of this permit shall not be construed as a guaMntee that the system will function as designed.
No.`rfll-i�C-
COMMONWEALTH Of MASSACHUSETTS
Board gof Heealth, � , MA.
DISPOSAL STSTEM CONSTRUCTION PERMIT
FEE.
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(Abandon( ) an individual sewage disposal system
at 26, as described in the application for
Disposal System Construction Permit No.,/ - dated,)
Provided: Construction shall be completed within 4b=e k- of tI e date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chetleslown, MA Date ��oard of Health /