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14
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a �/ �% COMMONWEALTH Of MASSAC USETTS
Type of Building i &xoz�4, ,%7� . Lot Size sq. ft.
Dwelling - No. of Bedrooms 73 Garbage grinder( )
Other -Type of Building No. ofersons Showers
p O, Cafeteria ( )
Other Fixtures /
Design Flow (mina r qu` ed) �/ gpd Calculated deign flow ��C.�`�y
Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil EvaluatorCALffW
ate of Evaluation _V146V10
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furtherMn t ce the s t in operation until a Certificate of C m_plian 'e / ssued by the Board of Health.
Signe Date
Inspections
Description "of Work:
The undersiLyned her
1Atf yV FEE
COMMONWEALTH OF MASSACHUSETTS ck-# I aq co
Board of Health, , MA. l t p 3
CERTIFICATE OF COMPLIANCE ���
0 Individual Component(s) DAComplete System
>y certify that the SewaZ Disposal System; Constructed (y�, epaired ( ), Upgraded ( ), Abandoned ( )
1416,
at
has been installed ii'n�accordance with the provisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application N/')o!.//'7 h_> dated ����° -1"7 Approved Design Flow � (gpd)
Installer ab''f�'10�6 . ! d� 7 ed //' 4; .� AX, - -
Designer: , , Inspector: �
Date: _
The issuance of this permit shall not be construed as a guar,/,e �at the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, � Ol , MA.
DISPOSAL. SYSTEM[ CONS1RUCTION PERMIT
�- to33 j
Permission its hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. 1 j dated t-1,7
Provided: Construction shall be completed within tl-rr of ffie date of this permi All local ceor� i ' ns must be met.
Form12�55/ev.5// 6 A.M.SulkinCo.Chatleslown,Mn Date�' ��"` Board of Health
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
PI
lication for a Permit to Construct(VrepairO Upgrade(
Abandon( - dComplete System -P Individual Co ponents
I
ocation d,37
Owner's Name
ap/Parcel#
Address r2� i6 �i
ot#
Telephone#
Installer's Name t1V
Designer's Name
Address
�'"� -''
��'"`
Address �,//�j�
Telephone#
�Ci
Telephone# --�'✓
i
Type of Building i &xoz�4, ,%7� . Lot Size sq. ft.
Dwelling - No. of Bedrooms 73 Garbage grinder( )
Other -Type of Building No. ofersons Showers
p O, Cafeteria ( )
Other Fixtures /
Design Flow (mina r qu` ed) �/ gpd Calculated deign flow ��C.�`�y
Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil EvaluatorCALffW
ate of Evaluation _V146V10
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furtherMn t ce the s t in operation until a Certificate of C m_plian 'e / ssued by the Board of Health.
Signe Date
Inspections
Description "of Work:
The undersiLyned her
1Atf yV FEE
COMMONWEALTH OF MASSACHUSETTS ck-# I aq co
Board of Health, , MA. l t p 3
CERTIFICATE OF COMPLIANCE ���
0 Individual Component(s) DAComplete System
>y certify that the SewaZ Disposal System; Constructed (y�, epaired ( ), Upgraded ( ), Abandoned ( )
1416,
at
has been installed ii'n�accordance with the provisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application N/')o!.//'7 h_> dated ����° -1"7 Approved Design Flow � (gpd)
Installer ab''f�'10�6 . ! d� 7 ed //' 4; .� AX, - -
Designer: , , Inspector: �
Date: _
The issuance of this permit shall not be construed as a guar,/,e �at the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, � Ol , MA.
DISPOSAL. SYSTEM[ CONS1RUCTION PERMIT
�- to33 j
Permission its hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. 1 j dated t-1,7
Provided: Construction shall be completed within tl-rr of ffie date of this permi All local ceor� i ' ns must be met.
Form12�55/ev.5// 6 A.M.SulkinCo.Chatleslown,Mn Date�' ��"` Board of Health
f