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No. D� �� � FEE
COMMONW4LT14 OF MASSAC14USETTS 7
Y�+RMOUTH HEALTH [SEP -r.
Board of Health, 1146 ROUTE 28 MA.
APPLICATION FOR DIS POSA1'S' "Yfl ' 1ION PERMIT
Application for a Permit to Construct( ) Repair (1'5Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Pomponents
Location G t pa—Owner's
Name_75A 5 l
Map/Parcel#
Address •S �"�j
Lot#
Telephone#
Installer's Name
Designer's Name
Address G
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min.
Plan: Date
gpd Calculated design flow
Number of sheets
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria ( )
Design flow provided
Revision Date
gpd
Title
Description of SolbN..
Soil Evaluator For Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS /9;�?X I Cef ID )-EO
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to/not to p!pethe system in operation until a Certificate of Compliance as been issued by the Board of Health.
Signed // V Date
Inspections
r t 1
No ^/ FEE
COMMONWEALTH OF MASSACIIUSETTS �
Board of Health, , MA.�/�
CERTIFICATE OF COMPLIANCE
Description of Work: ;b Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired 0, Upgraded ( ), Abandoned ( )
by: o C.., ice. C--r�
atr�'e
has been installed in accordance with the provisions �of 3x10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. p / , dated '5 —26C 5 Approved Design Flow ` (gpd)
Installer e l-5 U 4/9 4-'4 i
Designer: Inspector:
The issuance of this permit shall not be construed as a guarantee tha thf
Date: � 75
system will function as designed.
No -0 /' !�AIAL
CO9 MONWEALTO OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair(;/, Upgrade( ) Abandon( ) an individual sewage disposal system
at 'R-2 1 L If `7 " / I A ' rC as described in the application for
Disposal System Construction Permit No. dated � 210 G t�
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date _ ld Board of Health