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Board ofIlealth, yh✓iwI; , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Application for a Permit to Construct( ) Repair( ) Upgrade-�AbandonO -_ISComplete System O Individual Components
Location O� A ti 1 I
A� + u Owner's Name �
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Map/Parcel#
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Address 1 c J
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Lot#
Telephone# a)i,�
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Installer's Name l ;
�t/L Designer's,. Name cos,
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- ,-Address
Address
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Address v ��x
��Z Dauctwick i�,O
Telephone# -' Z2 1 `
; W ` Telephone# Soo • 52 _ 3 (v(7
Type of Building I. t Size sq. ft.
Dwelling- No. of Bedroomsm T Garbage grinder(
Other - Type of Building No. of persons Showers O,'Cafeteria
Other Fixtures �^�
Design Flow (min. required) 3 �l (i gpd Calculated design flow Design flow provided 7 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of.SoiillEvaluator Date of Evaluation
DESCRIPTION OF REPAIRS Olt ALTERATIONS � I � " c ;Pwdk5?�v (}' W /, ��L 2 h� 'i
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agree to not to p c� tihe stem in operap0
n until a Certificate �f' Co fiance has been issued by the Board of Health.
Signed ' W` lca Date 9 (
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Inspections
ley
No. 1'"1 ! C ��t, f FEE
,� �, C®�[�'Ii ONWEALT14 O MASSACHUSETTS o� 3-��-r410��
Board of Health,
rf—WO C14 MA.
CERTIFICATE OF COMPLIANCE
Description of Work; 0 Individual Component(s) 0'6omplete System
The"ersigned hereby! certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded`<),Abandoned
at i J
has been installed in accordance with the -ovisions of CMR 15.00 (Title 5) and � t� ef` pproved design plans/as-built plans relating to
application No. 1° " � dated Approved Design Flow _,1a (gpd)
Installer -
Designer: 'S1 14Ip Li Wk Inspector: Date:
The issuance of this permitshall not be .construed as a,guarto at the system will function as designed.
2 A" 1 A\Sj G:iC-a4\t` ! FEE
_ , COMMONWEALTH OF MASSACHUSETTS
Board of Health, . gM0 , MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is herebygranted to;, Construct( ) Repair( ) Upgrade- Abandon( ) an individual sewage disposal system
at 3N '' i1 I A. li �'F� % �? as described in the application for
Disposal System Construction Permit No. , dated %
Provided: Construction shall be completed within three years of the date of this permit.ocal conditio must be met:.
1
Form 1255 Rev. 5196 A.M. Sulkin Co. Chaileslowo, MA Date/,- oard of Health
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