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FEE 4-M C®NIM® ® MASVANWT �� '
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Board of Health, Z,
APPLICATION FOR DISPOSAL SYSTEM[ C®NSTRUCT%TH DEPT.
41
kndiApplication for a Permit to Construct( ) Repan-( ) Upgrade( ) Abandon( - ❑ Complete System vidual Components
Location p j lj
Owner's Name
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Map/Parcel;
Addressj64)
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Lot#
Telephone#
Installer's NamC1_1W..,0k11Designer's
Nan
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Addre G
v� Address
Telephone# L - —
Telephone#
77?
Type of Building If(l/s)! ✓ULA Lot Size sq. ft.
Dwelling - No. of Bedrooms 1Z_ Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. •equired) 7_20 gpd Calculated design flow ZZU Design flow provided gpd
Plan: Date 1 7 Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned es to, install a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr o Zto.lace system in operation until a Certificate of ompl'ance has been issued by the Board of Health.
Signed Date �/
Inspections
00
N
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COMMONWEALTH U'V' EALTH ®f MASSACHUSETTS " % d" ' -Ck*j-
Board of Health. Y>l 1 , MA.
r CERTIFICATE Of COMPLIANCE
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Description of Work: Individual Component(s) ❑ Complete Systemi���`'""��
The.undersign/e�dhereby certify that tl ewage Dispo al System; Constructed( ),Repaired( ), Upgraded (%klAbandoned ( )
at 5 ni ;rf/ 1,e
has been installed inacco Once with the pr A ion of 314 CMR 15.00 (Title 5) and the
application No.
�-— A roved Design Flow
, -dated pp
Installer bj, C r_C r' L ki i✓1 %a "L !
design plans/aMuilt plans relating to
Designer: tn 1 f (�y `! s^ t 6V Inspector: Date: "� 3
v
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. (•1;.C1` Gj c, cr 1KJA�- Cbt-S FEE
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0 ONWEALT14 OF MASSACHUSETTS
Board of Health, i (} X3.1) I ; MA.
DISPOSAL SYSTEM ST CONSTRUCTION PERMIT
Permission is hereby granted/ to; Construct( ) Repair(y< Upgrade Abandon( ) an individual sewage disposal system
at 7 2!7 4)71aQ dam- as described in the application for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed withirLxhrer/e� )f the date of this peryj� ,local conditions -Must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, M Date 10 Board of Health