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COMMONWEALTH OF MASSACHUSETTS
Board of Health, �1UJU MA. C�v ► �� �
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct4,4/Repair( ) Upgrade( ) Abandon( ) - 1I a Complete System ❑ Individual Components
Location M —1
a 5a' 6'JgjE7-*J' e$T 6 V
Owner's Name "
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Map/Parcel# /&I//
0 • >/ l P,f
Address C�
/
:�G (/z
'�p -
Lot# 14
Telephone#
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Installer's Name
�/�d� �'*IlL;
Designer's Name
Al � /; "1111
Address ��j t✓ LCry .�
Address? --7"92
41
Telephone# r4
;r ^
Telephone#
9
Type of Building %� e -P Lot Size r 7Y 2 C -r--% sq. ft
Dwelling - No. of Bedrooms om' Garbage grinder
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow Design flow provided 3`e i4 gpd
Plan: Date Number of sheets Revision Date
Title
Description of S'oii(s) _
Soil Evaluator Form No.
Name. of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS / " e�j Z
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage; Disposal System in accordance with the provisions of TITLE 5 and
further a , ees of to I e e tem in peration until a Certificate of C mpli ice has been issued by the Board of Health.
Signed Date /' .1
Inspections
No. — ZEE
COMMONWEALTH OF MASSACHUSETTS
Nl
Board of Health, � r , MA.�-
CERTIFICATE OF COMPLIANCE bi
Description of Work: U Individual Component(s) �JComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed j�Repaired ( ); Upgraded ( ), Abandoned ( )
by: y/-er•'✓ lf! /� �t�' C.o°"0' �t C°ill-� •��✓ • 1 1-4C.
at /I 4 -1 --en '. %® PI.s/ 4 k" h .1 <1 6.nPii-72 dBs@r�r,✓ �ts�
has been installedr in a,�,c_c``or ce with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.47-11T, T; dated ,2-z -t7Approved Design Flow _(gpd)
Tom'
:Installercar/ S' Lv's Ikw <. .e � .r► .,
Designer , (T � /lea -n- _ _ Inspector: y Date:
The issuance of this permit shall not be .construed as a guaran ee that the system will function as designed.
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No. 1> { r t \_ C, Ip gg 1 F 1
q2— COQ' MONW I,TH OF MASSACHUSETTS
Board of Health, y , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; ConstructV,<"Repair( ) Upgrade( ) Abandon( ) an indiv dualsewage disposal system
at J. 7a-, , / x d as described in the application for
Disposal System Construction Permit No. ; dated
Provided: Construction shall be completed within rs o the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chaftown, MA Date al r oard of Health /(
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