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FEE��
MMONW EALM Of MASSACHUSETTS
Board of Health, I4194A60-M , MA.
PR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Repair( ) UpgradeAbandon( ) ompiete System O Individual Components
Locations.
Owner's Name t
Map/Parcel# /D��
Address 3 i
Lot#
Telephone# �—�b::'-._ 5/25 Y_ tyZ Q3
Installer's NameDesigner's
Name.
Address
Address / e
Telephone# /
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building No. of persons
Size
Lot
sq. ft.
_ Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) �33 gpd Calculated design flow Design flow provided _� gPd
Plan: Date Number of sheets Revision Date
Title //ll
Description of Sbil (s) � &.,g 4 &9:t D
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
r
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 ees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _. Date
Inspections .1.1-17-17
Y
COMMONWEALTH OF MASSACHUSETTS. -V/ 7T.
Board ofHealth, �Z1a f1 t L�1� , MA,
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) dOoComplete System
The,undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( );Upgraded ( Abandoned O
by:
at F,
has been `installed in accordancf with the provisions of 310 C ' R 15.00 (Title'5 a the.approved design plans/as-built plans relanrig'to
application No. %� +�+ dated Approved Design'Flow(gpd) ,
Installer
Designer: ��--Inspector: _ Date:
The issuance of this permit shall not he conalle0 "apar • ee that the system will function as designed.
� e "�` 1'' ��,,� ----�� FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, VA o tnm 'JAM
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at _} t / r' as described in the application for
Disposal System Construction Permit No. date
Provided: Construction shall be completed within-7�c� rssoofftthe ate of this permit. ocal conditio s must be met.
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Form 1255 Rev. 5/96 A.M. sulk' n C . Chadeslown, MA -� ate ' � ,'"i 7BBoardof Health /
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