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COMMONWEALTH OF`IASSACH USETTS cow 3� q
Board of Health, VAgmbyrk MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for 1 Permit to Construct(\.Y'Repair( ) Upgrade( ) Abandon( 2Complete System ❑ Individual Components
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Location
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Owner's Name
Owner's
Map/Parcel# - -� S 3
S'w� ri
Address<n
Lot#
Telephone## gqT, . a
Installer's Name �
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Designer's Name
Address
Address 3 `
Telephone# G2=>X-- n60=Telephone#
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Type of Building t- -< ice"., a;_ Lot Size 06? �Gr fSsq-ff,
Dwelling - No. of Bedrooms a Garbage grinder
Other -Type of Building, No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) `o R ® gpd Calculated design flow Design flow provided 2 'cf3 gpd
Plan: Datec��C�Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil EvaluatorK V -,- Date of EvaluationZ 1
1410 _
DESCRIPTION OF REPAIRS OR ALTERATIONSr. ce .a l� ti SAO (S1
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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 place the syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed /` Date 2
Inspections
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Description of Work:
The undersigned hei
has been installed 'I
application No. j
Installer'^; -
Board of Health,MA.
CERTIFICATE OF COMPLIANCE 0 4 1��
Individual Comporient(s) O' mplete System Ill/0-51,
>y certify that the Sewage Disposal System; Constructed (tjRepaired ( ), Upgraded ( ), Abandoned (; )
accordance with the provisions of CMR 15.00 (Title 5) and he ap roved design plans/as-built plans relating to
dated. -" f Approved Design Flow (gpd)
Designer:; c ('r,. Ir , �1 Inspector:�e.`�"'1 Date: 1A.6
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. 7 "'
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, l g� ® un4
DISPOSAL SYSTEM CONSTRUCTIONPERMIT
Permission is hereby granted to, Construct(t_-)"_Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
``ec `; t.�- _r_ �^ C ">✓ �o _ � ev�'� 7 as described in the application for
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Disposal System Construction Permit No."f �, dated
Provided: Construction shall be completed within three years of the date of this permo 11 local connditiongnust be met.
Board of Health
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date