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No. F/ O � C^L C�' —1 415L l�j�Q - 1 v 0 U °, M f% --.4Z- / F
COMMONWEALTH OF MASS/ACAjafU/SEmS
Board of Health, t)T)+ , MA.
�A P I ATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for aPermit to Construct( ) Repair( ) Upgrade(44bandonO - 0Complete System ❑ Individual Components
Location 3
Type of Building Lot Size 2gov sq. ft.
- of Bedrooms Garbage grinder
Dwelling No.
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 di�
ofS'oii(s) �fie�i4
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
Owner's Name
y�
Map/Parcel# ►'1'
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Addressot j
Lot#
Telephone# T7 ..
Installer's Name
9U
Designer's NameG���
Address ��
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Address
Telephone#
Telephone# �'_�
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DDESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation u a Certificate of Co plias ce has been issued by the Board of Health.
Signed Date i (e �
COMMONWEALT14 Of MASS t�10-7 �
Board ofHealth,T fLIYZ b t_rT'ii-
CERTIFICATE Of COMPLIANCE .---
Description of Work:; ❑ Individual Component(s) G'Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ); Upgraded/ ( }
by: 21
at a _, c �"'
has been installed in acco nce with the pr visions o to CMR 15.00 (Title 5) and d6Kaaproved design plans/as-built plans relating to
application No. dated 1 Approved Design Flow ( pd) sr
1 f
l
�
Installer 7al a--
7
Designer: + .�a '� <. Inspector: J Date:
i
The issuance of this permit shall not be c/trued as a guaranlge'that the system will function as designed.
FEE c"•
..
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(..) Upgradel Abandon ( ) an individual, sewage disposal system
at (r iiY/ i { 7 ���' ! - L ; rt *-� +' ? .�tl described in.,the application for
Disposal System Construction Permit No., dated
vP'r
Provided: Construction shall be completed within iw i s of the date of this perWi . AAI( local condAns must be met.
Form 1255 Rev. 5196 A.M. Sulkin Cq'Chadesf�n, MA Date
�r Board of�Healtli
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