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71 _71� COMMONWEALTH Of MASSAC14USETTS j4z,-r t 2
Board of Health, �at3iZ 1Vi CilY3-bi , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairX Upgrade( ) Abandon( ) - ❑ Complete System XIndividual Components
Location
Owner's Name4&e S
Map/Parcel# Y%/(p(p
Address 10-:3,0 CG
Lot#
Telephone# �r - i
Installer's Name
Designer's Name
Address
Address
Telephone# �p
? (p 3 4OZ&(,�pTelephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( }
Other- Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils)
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 agrees to n ace the sin o on un ' Certificate of Compliance has been issued by the Board of Health.
Signed -VMS Date — -!
Inspections
No. 6•''c) 14 . LK- V :,
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COMMONWEALTH OF MASSAC14USETTS
Beard of Health, YAR.M013TH , MA.
CERTIFICATE Of COMPLIANCE -
Description of Work: X11dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaire O, Up raded ( ), Abandoned ( )
by: �.�-c r-, s ISG
at ? is U Cr LIV Z.
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application I`i`J %rated r/7. Approved Design Flow (gpd)
InstallertJ Wim' (]
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. d �IC. "� 7-00+ c
7 Q � t SAOC�'. FEE
7-r7LI COMMONWEALTH ® ASSC�J'T -i
Board of Health, f)M+ , 9A.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
R.epair(iU 'Upgrade( ) Abandon( ) an individual sewage disposal system
PPP ��` as described in the application for
Disposal System Construction Permit Nk QP, t>c> 2�4 dated , 7' GS -/,7
Provided:. Construction shall be completed within three years of the date of this permit. All local conditions most, be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 7- 6,'" i % Board of Health