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7 144 COMMONWIFAICTU ®f MAQQA CU1JQFTT1Q cVA1U) U
Board of Health, YPfZVAOIi'f A , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Ar. plication for a Permit to Construct( ) Repair(UpgradeO Abandon O - ❑ Complete System 0 Individual Components
Type of Building 1
Dwelling - No. of Bedrooms.
Other - Type of Building —
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd . Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the tem in operation until a Certificate of Co pliance has been issued by the Board of Health.
Signed Date
Inspections
FEE -1,S5.00
COMMONWEALTH OF MASSACHUSETTSa6 8'-'>v -7 Ik'44 51 e'770
Board of Health, A-i2.MOOnt , MA. CERTIFICATE OSE COMPLIANCE koik4�,
I/
Ak-
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ({/), Upgraded ( ), Abandoned ( )
by: `
at
has been installed in accor ani e with the provisions of 310 CMR 15.00 (Title 5) .and the approved design plans/as-built plans relating to
application No. ? f dated 1� 7 Approved Design Flow (gpd)
Installer ` • t'
Designer: Inspector:_16/
f % Date: _�
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
No. 500D.C_ 1-7 Ll 21-1 `'1 � 3 . 0 q
/.�� COMMONWEALTH Off' MASSACHUSETTS
Board of Health, %IZMQ UTV1 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEj !-s-n-. o
4;#(5'6" �
Permission is herebygranted to; Construct( ) Repair(o Upgrade( ) Abandon( ) an individual sewage disposal system
at-fat—faC2 &RAWU& as described in the application for
Disposal System Construction Permit No., dated 4
Provided: Construction shall be completed within three years of the date of this permit. All local conditions ustbe met.
Form 1265 Rev. 5/96 A.M. Sulkin Co. Chadesiavn,MA Date .� "! Hoard of Health Y ` 1A*
Address
Telephone#
'Ii�r
- - i �f��r..I �I �• �•
a .�� r.l,
Address,,
Type of Building 1
Dwelling - No. of Bedrooms.
Other - Type of Building —
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd . Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the tem in operation until a Certificate of Co pliance has been issued by the Board of Health.
Signed Date
Inspections
FEE -1,S5.00
COMMONWEALTH OF MASSACHUSETTSa6 8'-'>v -7 Ik'44 51 e'770
Board of Health, A-i2.MOOnt , MA. CERTIFICATE OSE COMPLIANCE koik4�,
I/
Ak-
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ({/), Upgraded ( ), Abandoned ( )
by: `
at
has been installed in accor ani e with the provisions of 310 CMR 15.00 (Title 5) .and the approved design plans/as-built plans relating to
application No. ? f dated 1� 7 Approved Design Flow (gpd)
Installer ` • t'
Designer: Inspector:_16/
f % Date: _�
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
No. 500D.C_ 1-7 Ll 21-1 `'1 � 3 . 0 q
/.�� COMMONWEALTH Off' MASSACHUSETTS
Board of Health, %IZMQ UTV1 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEj !-s-n-. o
4;#(5'6" �
Permission is herebygranted to; Construct( ) Repair(o Upgrade( ) Abandon( ) an individual sewage disposal system
at-fat—faC2 &RAWU& as described in the application for
Disposal System Construction Permit No., dated 4
Provided: Construction shall be completed within three years of the date of this permit. All local conditions ustbe met.
Form 1265 Rev. 5/96 A.M. Sulkin Co. Chadesiavn,MA Date .� "! Hoard of Health Y ` 1A*