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No. 1/�' ✓` —1 (`f(, 3 FEE i 6S� 60
7� COMMONWEALTH Of MASSACHUSETTS 7
Board of Health, lIT/�, �1�(� V J`� MA. Pl� f-
r T
PPLICATION FOR. DISPOSAL SYSTLM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgradoe-) Abandon( - ❑ Complete System ndividual Components
Location/ .
Owner's Name
Map/Parcel# / ` P 1
Address 86 �N
Lot#
Telephone# R2, 2-
Installer's
Installer's Name
Designer's Name
AddressQ,
Address
Telephone#
Telephone#
Type of Building �` / hot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder Ala
Other -Type of Buildin j No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow 3 Design flow provided gPd
Plan: Date Number off sheets Revision Date
Title olzz G /r/►/ - Al�J 1
Description of Soils)
Soil Evaluator Form No. Na e I f Soil Evaluator`/�s% Date of Evaluation
DES(
The undersigned agrees to install -the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no la e s tem ' o a ' until a Certificate of Compliance has been issued by the Board of Health.
Signed I Date '7 �2
Inspections
No. Q 17-3580 FEE t 57P . 00
17— COMMONWEALTH OF MASSACHUSETTS c it
Board of Health, t4V_M , MA.
CERTIFICATE OF COMPLIANCE
Description of Work; Jd'Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedAbandoned ( )
by:'
at
has been installed in acnce with the provisions 10 CM 5.00 (Title 5) and the a roved design plans/as-built plans relating to
application No. % % '" tJr-, dated Approved Design Flow _�(gpd)
Installer f f 's q
Designer: l' } ✓ldjJJ! 4// "l Inspector: 'r Date:
The issuance of this permit shal(not be co trued as a guarantee that the system will function as designed.
1 q SO FEE 55
OF, MASSACHUSETTS
COMMONWEALTH
f Board of Health, �' (L , MA.
�-
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) UpgradeV Abandon( ) an individual sewage disposal system
at `a IiV—" as described in the application for
Disposal System Construction Permit N dates
Provided: Construction shall be completed within t r- s oith� date of this permitlocal conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Dat �ff Board of Health r
i r