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No. oac-" 1 03s, 7-1, — 13 -?/ o77 FEE
1 7-->J6 COMMONWEALTH Of MASSAC114USETTS
Board of Health, �1J JTjt—, MA./ �( �`/ /4
APPLICATION FOM, DISPOSAL SYSTEM CONSTRUCTION S�PERM, IT
Application fora Permit to Construct( ) Repair( ) Upgrad - Abandon( - L1Complete System. a dividual Components
Location 6
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Owner's Name
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Map/Parcel#
5-'0/-q4j 7f
Address
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Lot#
Telephone#
Installer's Name
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Designer's Name
Address /
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Address /
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Telephone#
&[S„ (5 C) v
Telephone#
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 (mi65
en. required) �"i d gpd Calculated design flow �K l Design flow provided �l 1 gpd
Plan: Date 7 ` 7 o- /7 Number of sheets / Revision Date
Title
Description of Sbil (s) -� Ci C�i �A J,
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS _:Irll .4' I'a
h
of Evaluation 7" Z,.,.) - / 7
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 lace the sylpejn in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �� - �V 7
d 7-
- �� FEE ��• � �J
COMMONWEALTH Of MASSAC� TT o� .
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work; Q'Individual Component(s) ❑ Complete System 40,)c 'fie
4
The undersigned hereby certify that the+Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded(yAbandoned(
at AVE
has been installed in accordance with theprovisions o�10 CMR 15.00 (Title 5) and the ap r ved design plans/as-built plans relating to
application No. f - dated �� Approved Design Flow gpd)
Installer 114, tG '+
Designer: ����� /'Pfi9 Inspector: x� V ��.sat ��[ Date: /
The issuance of this permit shall not be construed as a gu tee that the system will function as designed.
No. i) i 1 C - 1�� -- - - - - -�� FEE �, V
/7 COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAS. SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system
at '° r as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within of the date of this perm i All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA -Date Board of Health