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v: No. 6ogPC—(i 3784
k, � 7- �� ®NWEALTH OF MASS C14USETTS
11L�2ar6 of Health, "/� MA.
r, r� "O/APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION FERMI
FEE �r
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2, pp ication for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - Complete System ❑ Individual Components
Location ? J
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Owner's Name
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Map/Parcel#
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Address f—
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Lot#
Telephone#
Installer's Name
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Designer's Name
Address
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Address
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Telephone# G
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Telephone#
Type of Building C r Lot Size sq. £t.
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
Pian: 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 totop ce th tem ' o 'on until a Certificate of °6mp 'ance has been issued by the Board of Health.
Signed � :Date100,
Inspections /2 7 �J7�/�� Of
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No. i�CN��-i?-�i%Qi�t � lel}°rFEE- _a,W
Beard of Health, I 1 ('} , MA. ; ,a
CERTIFICATE OF COMPLIANCE �'�Oy � � �
Description of Work; aIndividual Component(s) ❑ Complete System �7
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded 4,.Y bandoned ( )
at 7— X:: '/ids r/J -77—
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 No. �7:- dated ��. Approved Design Flow (gpd)
Installer
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Designer: me) r2..) Inspector: ( Date;=lam—Tri—
The issuance of this permit shall not be construed as a guarant that the system will function as designed.
No. 6t oix--o 37,SLl FEE 1 C:fi
COMMONWEALTH OF MASSACHUSETTS 4417Oq
Board of Health, �—' MA.
DISPOSAL SYSTEq CONSTRUCTION PERMIT
Permission is hereby granted to; Constructt() Repair( ) Upgrade (Abandon ( ) an individual sewage disposal system
at 7f7 . as described in the application for
Disposal System Construction Permit No., dated
-17
Provided: Construction shall be completed within da= �ZZ tthe date of this perm', . All local conditions most be met.
Form
1255' Rev. 5/96 A.M. Sulkin Co. Chadestown, MA / Date _ `-� Board of Health
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