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COMMONWEALTH Of MASSACHUSETTS
Board of llealth,MA.
APPLICATIOR DISPOSAL SYSTEM C NS RUCTION PERMIT
Application for a Permit to Construct Rep ( air( ) Upgrad , Abandon - Complete System ca Individual Components
Location
(/'(;
Owner's Name re f,1J 'F' l�i �e� 1
Map/Parcel#
--
Address
Lot#
Telephone#
Installer's Name '
1
�� Designer's Name
Address
Add a r m odtk
oJ�fq—
Telephone#
rr
Telephone# ems.
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) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of S'oil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the a described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further a not lac tem in opera t' until,a Certificate of Co i ce has been issued by the Board of Health.
Signed PDate /� 7
Inspections." —
-47-
FEE . tic.
COMMONWEALTH Of MASSACHUSETTS
Board of Health,
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) GTO omplete System
The undersigned hereby certify that'the Sewa&e Disposal System; Constructed,. <iepaired ( ), Upgraded ( },Abandoned ( }
by:
d11 t � U4+"( c" d I '
3t.
has been installed, in accord apce with the provisions of 310 CMR 15.00 (Title 5) and the a oved design plans/as-built plans relating to
application No. dated '�'-7 Approved Design Flow (gpd)
Installer -S -9-7}(C^ A
Designer�P G'r t_ Inspector: } �t '` t date:
_.
The issuance of this permit, shall not be construed as a j;uaraj3tKthat the "system will funct gn" as designed,
No. V--� � "`''� � (� �. {J �'� 3 -t--X �. FEE
-7 ��`�
- � 7 COMMON LTH Of MASSAC USETT� �
Board of Healtli, V "1 W , _ ,
DISPOSAL SYSTEM CO)61 CTERMIT
Permission is herebygranted to; Construct(
at
( ) Abaydon(-) andn�divikdual,sewage disposal system
�. 4. as de-46bed in t4r ap
`mow
Disposal System Construction Permit No.r dateda_ '`, "`
s o t e date of this.- permit. All local conditions must be ;met.
..Provided: Construction shall. be completed withnee�1
sN Form 1255 Rev. 5196 A.M. Sulkin Co. Chdestown, MA Date ! 7Board of Health (✓` ' �/