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SACHUSETTS
Board of Health, Yt, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon,( ) - ❑ Complete System O Individual Components
Location H 3 M o q d ct ,S'
Owner's Name ,Yo—
C 4 *L r Q vi�i/ !l
Map/Parcel#
Address
�
Lot#
Telephone# w
LL ci3- OQIJ /.p
Installer's Name v 1�S C �h oL
Designer's Name �..
Addres r' !/UJL
Address
Telephone# SeE If A. a
Telephone#
go
J
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) gpd Calculated design flow Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Description of goil(s) _
Soil Evaluator Form No,
DESCRIPTION OF REPAIRS
/f �..1 _ P n
Name of Soil Evaluator
TIONS ✓• 1,
Date of Evaluation
The undersigned afire o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n o piac a atl�ie�until a Certificate of Compliance has been issued by the Board"of Health.
Signed Date i
r
Inspections
No, )O i T (' f U �t FEE i -j . Uo
COMMONWEALTH OF MASSACHUSETTS -2-?.-3 �
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Board of Health, AMl�% , MA.
11 1
CERTIFICATE Of COMPLIANCE1- �i--k%'
Description of Work: ❑ Individual Component(s) ❑ Complete System
Thq undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( }
by:
r
at ,° j' , 1/, -
has
✓ has been installed in accgrd c ath the&rovisi ins of 310 CMR ..00 (Title 5) and4e approved design plans/as-built plans relating to
application No. r1 " /, =dated _ Approved Design Flow -- (gpd)
Installer i7 I 1
Designer: Inspector:. Date:
The issuance of this permit shall not be construed as a guapZe that the system will function as designed.
No. - ( 1 F `� i FEE . 6 o
/ COMMONWEALTH OF MASSACHUSETTS 2-2 3
Board of Health, `MA.
7.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at ! ,/) y i ? C h! �. cK r `% �--,,i e, as described in the application for
Disposal System Construction Permit No. :� dated
Provided: Construction shall be completed within t<� sY ofT e date of this perini Asll local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chateslown, MA Date " `� /) Board"of Health �`