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w �r"�(�iL !" xard of Health, ��rr�rG� MA.eko%
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERM
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le 6 Vp4cation for a Permit to Construct( ) Repaite/Upgrade( ) Abandon( ❑ Complete System Jd'lndividualnts -;�
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Owner's Name a��
ap/Parcel#
Address
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Telephone#
I staller's Name Gre'r�2
Designer's Name
ddress aAddress
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�Telephone#Telephone#off_
Type of Building i7';rA4�. riiv 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) gpd Calculated design flow Design flow provided 7 gpd
Plan: Date ��7/�8 Number of sheets Revision Date
Title 'ZEZE e
Description of Soil(s) .ufe�a�/'rr•� �So.9-3.5-
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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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 system ' pezation until a Certificate of Compliance has been issued by the Board of Health.
Signed-G� Date
Ac tions le .—A )- --/5?/l� '��/ C 'rL��' r e d11-- e" [ r Xpeee
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Board of Health, MA. o _ , _
CERTIFICATE Off' COMPLIANCE
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Description of Work: ❑ Individual Component(s) 'Complete System
The undersigned hereby certify that the.Sewage Disposal System; Constructed ( ), Repaired kUpgraded ( ), Abandoned O
by:
at
has been installed i accordance with the provis sof 10 CMR 15.00 (Title 5) and the approved' design plans/as-built plans relating to
application No. �! , dated U% Approved Design Flowt �. _(gpd)
Installer -G' f�=—� RIX,
Designer: ii/ (i(i' Inspector: �= t Date:
The issuance of this permit shallnot be construed as a guarantee that the system will function as designed.
No. a�4 C-1 -01b5 coE cc)D S c- svc5
COMMONWEALTH OF MASSAC14USETTS
Board of Health, Af MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
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Permission is hereby granted to; Construct() Repair(UUpgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. —'/' , dated
Provided: Construction shall be completed withi*-t4re�-�r oithe date of thy' per it. All local c ditions must be met.
e��Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dat ! '^ d Board of Health