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Board of Health, YI MO
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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plication fora Permit to Construct( Repair( ) Up
gradeandouO - Compiete'System D Individual Components
Location
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Owner's Name
Map/Parcel#
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Address 7.0
Lot#
Telephone## '. —37 —
Installer's Name
Designer's Name
Address
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Address ,Re_3 S,�r
Telephone#
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms) Garbage grinder {
Other - Type of Building No. of persons Showers O , Cafeteria
Other Fixtures
Design Flow (min. required) ^ 33 9 gpd Calculated design flow Design flow provided'._ gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils) .6
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
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DESCRIPTION OF REPAIRS OR ALTERATIONS
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 operatio ntil a Certificate of Compliance has been issued by the Board of Health.
Signed Date f/- �1 �� r7
.Inspections
No. '�-�.tC�• /�'\/�/ J / FEE _ 5
COMMONWEA CT14 OF MASSACHUSETTS A- sVt
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Board
�ofHealth, �jytjj� rjj�,j(jj IMSA.
CERTIFICATE ICATJI..� O CQl'JIPLL.7��,,�JnL.
Description of Work: ❑ Individual Component(s), f<omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired O, Upgraded pp, Abandoned O`
at
has been installed in Acorda ce with the rovisi?ns of 310 CMR 15.00 (Title and thea proved design plans/as,-built plans relating to
application No. % 7` dated 7. Approved Design Flow (gpd)
Installer 9f— / pVit �i
- .3' Date:
Designer: Inspector: The issuance of this permit shall not be co trued as a,guarradee that the system will function as designed.
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# _ % COMMONWEALTH Of MASSACHUSETTS � 10 690
.: Board of Health, �%�ir}� c.r�1- .
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Upgrade) Abandon( ) an individual sewage disposal system
at iii f r�/.�>,/ cf/�f'z'�� as described in. the application for
Disposal Syst—� em C nstruction Permit N , dated)%
Provided: Construction shall be completed within aixe ears of the date of this eri if. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Go. Chatealown, MA Date (� -/—.Zoard of Health f