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No. VV
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COMMONWEALTH Of MASSACHUSETTS
Board of Health,"l , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (/(Upgrade( ) Abandon( ❑ Complete System 1(Individual Components
Location j yi
Owner's Namel ¢ d
Map/Parcel#
Address PID
Lot#
Telephone# � 1/92- -1195
Installer's Name 7i �r WO S - -,
Ir
Designer's,Name 4-," nc
Address ` l jk VX�
Address ��, 6�Co%$-
Telephone# _ �tf
Telephone#(a�
Type of Building Lot Size sq. ft;
Dwelling - No. of Bedrooms Garbage grinder(
Other - Type of Building No. of persons Showers ( ), Cafeteria {
Other Fixtures
Design Flow (min. required)
Pian: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to ' the abs' described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 -and
further agrees to not to ace a tem ' operation until a Certificate of Com liance has been issued by the Board of Health.
Signed Date l �l
Inspections
) FEE : i�+fi. Z r! ? ,
No. l /
COMMONWEALT14 OF MASSAC14USETTS � � f 6,V
Board of Health, � Irn-i , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: L1 by dividual Component(s) O Complete System
The' undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (r ), Upgraded ( ), Abandoned ( )' /Js' fl,
by ,fZr � � � n t i n r� } A- c-'- ej
at
r � s
has been installed inAaccordance with the provisi,�ns of IO CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 'le —i � 1 dated -f- -/j Approved Design Flow (gpd)
Installer �n`" it v t t ( —Loc
Designer: y A ., , Inspector: •+ ly ''� {'� Date: id
The issuance of thispermit shall not be construed as a guarantee that the system will function as designed.
No. % -
COMMONWEALTH OF MASSACHUSETTS
Board of Healtl ,, MA.
DISPOSAL SYSTEM C®NSTRUCTIONT PERMIT
Disposal
FEE
( ) an individual sewage disposal system
— as described in the application for
Provided: Construction shall be completed within three years of the date of this pQr it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date Board of Health (: e G
s -