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No. s FEE
COMMONW ALTII Of MASSACHUSETTS
WCUTH HEALTH DEP 1, `rt �` �R " U GC
Board of H��pA1 ff E ?A , MA.
��'�/�PPLICATION FOP, DIMRA'TM. M �f KSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeVj'*Abandon() - Complete System ❑ Individual Components
Location a (�
Owner's Name
���
Map/Parcel# t4oa 1
Address 171 5
Lot#
Telephone#
Installer's Name
Designer's Name
Address
Addressea
Telephone# -
Telephone#�
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Sbil(s)
Soil Evaluator Form No. O Name of Soil Evaluator Date of Evaluation
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 a es to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 1� ti
Y
Inspections
-3 If- S .
No. U / 1 FEE
COMMONWEALTH Of MASSACHUSETTS ��� � s a 6-e
Board o Health MA.
f ,
CERTIFICAE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Z_C`omplete System -
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by: ('/
at a -
has been installed in accordance with the rovision 310 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No. Q� "7f ,dated - Ap roved Design Flow and
'Installer
ti✓ �i cz Inspector: Date:
Designer:
pkissuance o�f�-f' permit shall not be construed as a guar . tee thatthe system will function as designed.
No. (J f �/ f K^i i_Gt_S`( lam' FEE r% V
COMMONWEALT14 OF MASSACHUSETTS 6�R
Board of Health, 44r4 -,,Z MA.
DISPOSAL SYSTrM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ;;) Upgrade (i -'j Abandon( ) an individual sewage disposal system
at-,:,? 7 a )At,Y, � C� as described in the application for
Disposal System Construction Permit No. U / 171 dated e /1 C
Provided: Construction shall be completed within & s o the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. k 19, Co. Boston, MA DateF-( te�2,5�lloa rddf Health
/bin Al t I" e .vas b- AA ���o O �i / /lam ,,,,