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• ��� 1145 ROUTE � MA. 44-8 Casco Board of Health,
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
• Ap lication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location 1 _
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Owner's Name Ro akP-7
f! -'I-J %i -r C"o L /
Map/Parcel# 17- Z Lo T/ Z O
Address 1-7-3�-
Lot#
Telephone#
Installer's Name r
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Designer's Name FOn1s4 L t�. 4!:�4 D 1 L L
Address 32- L W.1`30
ec,� T�`'�- ',
Address p r $ ea
Z S-A 0-01 . OZ&7
Telephone!(.5-o e, at977p7-
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Telephone# S'O37-5--'CI-700
Type of Building ��Ti4 + �- G' O O t S ' Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) Z Z-0 gpd Calculated design flow Z 5-0 Design flow provided 3 3 o gpd
Plan: Date l , Z-0 0 2- Number of sheets Revision Date
Title
Description of So 11(s) S� Pt. P I- A /J
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -Ir C/L P L)4 /J
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• The undersigned agrees t ms(-alt&w tall the above describ Individual Sewage isposal System in accordance with the provisions of TITLE 5 and
further agrees to noo ace a system ' operation until a Certificate of Compliant has been issued by the Board of Health.
Signed Date O t Z Z-0 8 3
Inspections /` `Z'l'S �'la�^�J dk C %&t5& Cd►�i'CQI� ^� /�� // �-�`(J l F -tri -Ht
No. FEE
COMMONWEALT14®f MASSAC14US ETTS
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Board of Health,/K;LfL(ckJ MA.
CERTIFICATE Of COMPLIANCE �-�.� � � � � a �,
Description of Work: U Individual Component(s)p y
--i�'COm Tete System
i
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ko, Abandoned ( )
at ! 7 I< --f (tea (` •. ( fir __
has been installetin a corda ce with 1T7eprovisions `df -310 CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to
application No. `, dated =� 3- �--� Approved Design Flow?40 (gpd)
Installer � � i .�'�t r-��f�e) .ti i
Designer: 1r. C- I,:; k-0 � c.t -F\ C- Inspector: &Ltl•�/! Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, jai rZ-M(� ( ;"-f-( MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE�1r�C)
" 37-0 1 `7
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( Abandon ( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. , dated 0-��
Cn b"w�
Provided: Construction shall be completed within tb=-tears of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date f Board of Health /�0 /,/ C/ i -' �7-�
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