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No. �? V 6 �p ir-v` FEE 4th�D L�
W ®MMON LTH OF I SS CHUSETTS 3532
Board of Health, MA.
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repaii>KUpgrade( ) Abandon( ) - ❑ Complete System >Individual Components
Location aWOO yewe 1?04J
Owner's Name
r AA,, G'a
Map/Parcel# 63 3S
Address
Lot# / A
Telephone#
Installer's Name ��� Ll CGa�T✓�/t�l�'1
Designer's Name
Ju to I^rpA-
Address U X -� p-r,cv�� M./¢
Address j#''
_w%"c Ke)_ r®t A 9;A►n.Y >M0
Telephone# S'U •- 7%6 _ G e 0
Telephone#
_ 14 S -
Type of Building '` 5%rdt%n )1`'S / Lot Size 31 9 l, C/ sq. ft.
Dwelling - No. of Bedrooms T W 0 Garbage grinder ( }
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) tic gpd Calculated de ign flow aaa1
� a Design flow provided Q38 s ,�� gpd
Plan: Date �q 61 Number of sheets Revision Date
Title
Ir t�
Drescription of Soil (s) d J !e_ 9 co a., It--
Soil
tZSoil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Sf e �� PUD Ch tiN b e,- S� )) -5-9-S--4
:7 C/ G�j
00
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to_UQt to place the system in operation until a Certificate of Coyriplia7ce has been issued by the Board of Health.
Signed Date ®y '1 G
1�? .
No.
COMMONWEALTH Of MASSACUUS TTS �� ��, �
Board of Health, Yawn I MA --
CERTIFICATE OF COMPLIANCE ,._ /
Description of Work: ndividual Component(s) ❑ Complete System ��� C, rd / h
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned( )
has been installed in accordance with the provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. '~, dated " - '" -7 Approved Design Flow _(gpd) ? ", 1j 2
Installer 4. )Z: _-_-_-
Designer: c �'�i .$ed/" Inspector:1 ,- MA Y" ISR -ate:
The issuance of this permit shall not be construed as a guar tee that the system will functi as9/signed.
/7- COMMONWEALTH OF MASSACHUSETTS
Board of Health, ) AAM ii r , MA.
DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
FEE 155 0
53?,
Permission is hereby granted to; Construct( ) Repairrk-upgrade ( ) Abandon ( ) an individual sewage disposal system
at �� GG�I �✓''(�, U� as described in the application for
Disposal System Construction Permit No. ;�q dated �7
Provided: Construction shall be completed within r the date of this permit. All local col ditions must be met.
Form 1255 Rev. 5,f/96 A.M. Sulkin Co. Chadeslown, MA Date _ Board of Health
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