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No, t/0� ! �Cr^ —O O 1 ,53,0 FEE
COMMONWEALTH OF MASSACHUSETTS
\j X37
Board of Health, YYJM + , MA.
• f
' APPLICATION FO DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade0 Abandon( - LlComplete System EJIndividual Components
Location
Owner's Nam
Map/Parcel# ,; �1� _
Address
Lot#
Telephone#
Installer's Name r
Designer's Name S
Address y
Address -
Telephone# 1 - Z&n,
Telephone#
Type of Building�if CSL/ i`tLCi 1,ot Size _ sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons. Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required) 22c� gpd Calculated design flow -3 Design flow provided_ gpd
Plan: Date --7 Number of sheets Revision Date
Title
Description of.Sbil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersi agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ee o oft la a th tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed +' Date -%;- -Z±g /7
Inspections
No. i 1 l .. j' FEE��rY
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, )ate. l) A , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The uiid`e nedhereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedfKl)','Abandoned ( }
by: ! G:-. sem'
at
has been nstalle in acetc�drdance with the provisioyns of 310 CMR 15.00 (Title 5) and the oved design plans/as-built plans relating to
application No. 1 7- t1 �" dated �i �"� to ' 7 Approved Design Flow'(gpd)
Installer(t
Designer: VJ s Inspector: el'.✓' Date: _
The issuance of this permit shall not be construed as a guarantee that the system.will function as designed.
7- COMMONWEALTH OF MASSACHUSETTS
Board of Health, )(fi �. O t D'i a , MA.
DISPOSAL SYSTEM CONSTRUCTION HERMIT
MWWfA�
FCE, y`� � � � �✓_
Permission is hereby granted to; Construct( ) Repair( ) Upgraded/) Abandon( ) an individual sewage disposal system
at -142 i� ffr as described in the application for
Disposal System Construction Permit No. f , dated
Provided: Construction shall be completed within -4i _ V of"the date of thiwetmit. All local conditions must be met.
/I IForm 1255' Rev. 5/96 A.M. Sulk!" C . Chad e t- MA Date *7 � /�$oard of Health �_� ( x`1
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