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COMMONWEALTH OF MASSACHUSETTS 40 � q 405-5-- 444691g
Board of Health, �j PrP -Mo OT -q MA.
r APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
lfcation for a Permit to ConstructRepairO Upgrade( Abandon( -omplete System O Individual Components
Location 52-
0, 5 e„t M
Owner's Name
Map/Parcel# A,s
1*511-
Address, Jei(o(Ae Ave- Icov,�W
Lot#
Telephone# ew- 016. 41
Installer's Name Ql l���t�-"
Designer's Name. k) /
Address 1
Address 3 �.� Z Ak m
Telephone#
Telephone#�%
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) O gpd Calculated design flow Design flow provided �6 3 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Mone 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 agree not lace the system in operation until a Certificate of Co piiance has been issued by the Board of Health.
M-24
Signed Date
Inspections
�C ck 6 r (G--,, L,41
No. c.4,6 -e7 COMMONWEALTH OF MASSACHUSETTS
Board of Health, p_Moun MA.
CERTIFICATE Of COMPLIANCE
FEE Y'1 00
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Description of Work: O ErCo
.�f GoIndividual Component(s) mpTete System
The undersigned hereby certify thattthe Sewage Disposal System; Constructed„' R paired { ), Upgraded ( ), Abandoned/I t ( },
by:
at i.. F t `` ut�,..-
has been install d m ac�d6 Awith eTrr4ions of 310 CMR 15.00 (Title 5) and t e proved design plans/as-built plans relating to
application No. ,- dated %4. Approved Design Flow (gpd)
Installer ,I"1C1. . ; ,� �' 1 Irl ' — M
Designer: ,5 efo uxo - Inspector: 1 Date: "'d% 4 -7
The issuance of this permit shall not be construed as a guarana that the system will function as designed.
No. % 1 C�C-� ` p f � C44A. s c- i- M M'A tUr FEE
16 4 COMMONWEALTH OF MASSACHUSETTS 0
Board (?f Health, /11 MA.
DLSPOSA SYSTEM CONSTRUCTION PERMIT 00 rbM�
Permission 3 hereby granted to; Construc Repair ( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. /tn -' , dated
Provided: Construction shall be complete �d�wi h� t;L1r„t:cZg '°of the d to of this permit. All local conditions must be met.
A
Form 1255 Rev. 5/96 A.M. Suakin Co. Chadestown, MA Date-:rGoard of ITealth t er %