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/7 COMMONWEALTH OF MASSAC14USETTS
Board of Health, Y%�'�011
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(-<bandon( ) - 'a-KImplete System O Individual Components
Location 3d� 5a.�'
Owner's Name
Map/Parcel# , (
Address
Lot#
Telephone#
Installer's Name
Designer's Name. G '
Address e.7
Address �� '" �, 2 S
Telephone#22VZ21Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided _53&? gpd
Plan: Date Number of sheets Revision Date
Title
Description of Sbil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
r t
DESCRIPTION OF REPAIRS OR ALTERATIONS e/
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 opera tio til a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
IN
111
No. 5C)HDC
EE
COMMONWEALTH OF NIRS ACHUATIS etc - 2-5-r�
Board of Health, MA.
CERTIFICATE Off' C®�' PUANC
Description of Work: ❑ Individual Component(s,) .fit Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired( ),Upgraded (ndoned ( )
by: 41 Nwe
at . -o4e7 .4 "r -t, ;?�s
1.
has been installed in accordance with the provisions of 310 CMR 15.00 (Tffle 5) and•ihe approved design plans/as-built plans relating to
application No. z dated -7. approved Design Flow"(gpd)
Installer ' i 4: OK'd %0,L IJ
Designer: g . .4 lzi4 Xi Ins�ector: ' . Date:
The issuance of this permit shall not be construed as a'guarantee that the system will function as designed.
_ � / lJ ) clv
No. FEE
T'dl
Board of Health, vi p' --M Ci 1-mA , ,MA.
r�0,
DISPOSAL ,SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade A andon( )an individual sewage disposal system
at J o 15 �? "d .� as described in the application for
Disposal System Construction Permit No.� _, dated /
Provided: Construction shall be completed within ire years of the date of this permit. N1 local conditAns must be met.
4` Form 1255 Rev. 5/96 A.M. Sulkin Co. Chaaeslown, MA Date '-"% ~ ///Board of Health �✓
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