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No. -00 Oc, � FEE
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COMMONWEALTH 01F MASSACHUSETTS Ck,,#
o Health, r MA.
Aift DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct O Repair( ) Upgrade�bandon( ) - v Complete System ❑ Individual Components
Location D �
Owner's Name Pv �-
Map/Parcel# 1,39
Address _/7
Lot# e
Telephone#
installer's Name 13p+� ��CU ° "—
Designer's Name
Address f �$ A' d
Address
Telephone#'` a g
Telephone#
Type of Building Lot > � Size 0")S8 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers( ), Cafeteria �)
Other Fixtures
Design Flow (mina required)
Plait: Date _ 9:-5,
L/U gpd Calculated design flow Design flow provi ed gpd
Number of sheets I Revision Date Cc
Title ���" ti� 0 4J E- 4C t_A�f/Ya Sc4� v� tYNV`
Description of Soils) A --
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to pla a tem in operation until a Certificate of Co plias a has been issued by the Board of Health.
Signed Date /
Inspections
No./_� 7`-� Q'-. FEES
COMMONWEALTH OF MASSACHUS ETa .18-oa azopk- T a�
Board of Health, ®-7W MA.
CERTI ��Plte
Of COMPLIANCE
p( -
Description of Work: ❑ Individual Component(s) System
The undersigned PerSbypgtify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (+- , andoned ( )
by: (/
at y'd
has been installed in accorda ce with the rov'si s oQ10 CMR 15.00 (Title 5) and th a proved design pians/as-built plans relating to
application No. '��� ^,�daattedr-, _7 1 . Approved Design Flow�F F V (gpdd WI -
Installer% M® �� /d?`y/K �� �/Y� LL '/►�l �i[ /iW
Designer: 6&�f /�� �, _ Inspector: Date:
The issuance of this permit shall
4not be construed as a guarantee/ that the system will function as designed.
COMMONWEALT14 OF MASSACHUSETTS
Permission is hereby granted
at
FEE
Board of Health, , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
;i Constrtkct( ) Repair ) Upgrade{ 4-,' �andon ( ) an individual sewage disposal system
GJI�� 4°h as described in the application for
Disposal System Construction Permit No./ 7 , dated —.9—/7.
Provided: Construction shall be completed within>>=tree years of the date of t=PeAll local corAidons must be met.
Form 1255 Re 5/96 A . Sulkin Co. Chadestown, MA DateF'1k Board of Health