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No. DC-47--0S`I 1r�L_VTIZ_-1 — W_L(�(01,L7, FEE
7-)0 COMMONWEALTH OF MASSACHUSETTS cow
Board of Ilealth, MA. tv k
APPLICATION FOR DISPOSAL SYSTEM STEM CONSTRUCTIO PERMIT
Application for a Permit to Construct/Repair( ) Upgrade( ) Abandon( - UYComplete System 0 Individual Components
Location
avz, "-
Owner's Name C,. A!i 414 i l'f i -J
Map/Parcel#
eo 197
Address "00. /7v X 1a to f �-yv,
Lot#
Telephone# ",f - 7J,7- C/-7 0 7
Installer's Name
/A/4 fir dl
Designer's Name Nei
Address P v
ABX' /.?/0-
Address /0_9.
Telephone# J -b p. 3 9 Sr_ Sv s/
Telephone# s -o`
Type of Building Ae .lp4c Au e 17VMe Lot Size �/¢i 7-" sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) 33 ,0 gpd Calculated design flow Y� • ds" Design flow provided 3V A-• a'" gpd
Plan: Date /0 -- /d •- / 7 Number of sheets a Revision Date
Title ✓'jy ✓ •k H
Description of Soil(s) Lo A M rg" Loll /y""Vv farms
Soil Evaluator Form No. Name of Soil Evaluator Paw e u Re.� Date of Evaluation AO // - 7
DESCRIPTION OF REPAIRS OR ALTERATIONS A/ew ✓ The ✓%✓ �ra►-
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 system in operation until a Certificate of Compliance has been issued by the Board of Health..
Signed OCA-- Date //- 9_ 17
0
Inspections
No. d{iDC_j /--09c,•1 FEE 55,00
7•-'„+_ � COMMONWEALTH Of MASSACHUSETTS .- H
Board of Health, y'., a V734 , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (Repaired ( ), UpgradedE f Abandoned ( )
by: i! ! /7 ; f r' 7 l c ! C ry.r .., ..! A/ C.
at `f ?t✓ c k Jr, s 1'y'i c u fly
has been installed in accordapce with the provisions of IA CMR 15.00 (Title 5) ag�d``t``he ap roved design plans/as-built plans relating to
application No. % off, / , dated �/ /�: . Approved Design Flow ge. (gpd)
Installer
Designer: .�DC)`' Inspector* Date:..�.
The issuance of this permit shall not be construed as a,guaran ee that the system will function as designed.
No.>6C'i 'L / lU' i !i 7�� ��%.� FEE �,✓ .
COMMONWEALTH Of MASSACHUSETTS
Board of Healt)c, �1 ® V71+ , MA.
DISPOSAL SYSTEM CONSTRUCTIONPERMIT
•
Permission is herebygranted to; Construct( ) Repair( ) Upgrade ,Abandon( ) an individual sewage disposal system
at
,; 1
Disposal System Construction Permit No. 0--..J- 497, dated.
Provided: Construction shall be completed within t date of this permit • A-1.1 local c, nd' ' ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date // �_7Board of Health �- "�
as described in the application for