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7 COMMONWEALTH OF MASSACHUSETTS � 1 77�5�
Board of Health, Yft9MQ On4 NM.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct )Repair( Upgrade( ) Abandon O 0 Complete System �dividual Components
Location
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Owner's Name \ ,
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name � j�
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esigner'sName
Address
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Address
Telephone#
Telephone*
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min, required)
Plan: Date
Lot Size sq. ft.
Garbage grinder {
No. of persons Showers (3, Cafeteria
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation
The undersigned a ees to install a above described Individual Sewage Disposal System in accordance with the provisions of TULE 5 and
further agrees t o place tem. in operation until a Certificateof Co pIiance has been issued by the Board of Health.
Signed f -� Date :)e,1,7
No. is
�40-
Description of Work:.
The undersigned her
by:
at
COMMONWEALT14 OF MASSACHUSETTS 40P � FEE
Board of Health, _Y 0160iffil--, MA. /
CERTIFICATE Of COMPLIANCE A IV 1101 ,
individual Component(s) ❑Complete System,✓r 74f 91 f /;
cer that the Sewage Disposal System; Constructed( ),Repaired upgraded( ), bandoned (
has been installed in accord, e with the ovisio//ns of 310 CMR 15.00'.,(Title 5) and the approved design plans/as-built plans relating to
application No. / ! _ , dated Approved Design Flow (gpd)
Installer /0 s —4
Designer: � � Inspector: /- r -1-c Date: _
The issuance of this permit shall not be ,construed as a guarani a that the system will function as designed.
No. - - - — - — - - ----
l7- COMMONWEALTH OF MASSACHUSETTS
Board of Health, OM O U TV , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;
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FEE' r 6J (J
Repair(-*rUpgrade( ) Abandon( ) an individual sewage disposal system
Disposal System Construction Permit No... dated !/ .
as described in. the application for
Provided: Construction shall be completed within three years of the date of this permit. All local cond' 'ons must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Go. Chadestown, MA Date �`: b ' //Board of Health
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