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/7-/ PMMONWEALT14 OF MASS C14USETTS
Board of Health, YOin- , MA.
;XZ1ATTON FOR DISPOSAL SYSTEM CONS" UCTION PERM IT
Application for a Permit to Construct( ) Repair( ) Upgrade�Abandon( ) - Complete System ❑ Individual Components
Location !,?'I
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Owner's Name I_uns -Sf&A t-ri,, fin/
Map/Parcel#
l b 6 16-7
Address S4tl (:
Lot#
Telephone#
Installer's Name
S �Q 1/ ( U�7i�
Designer's Name pA,v A .SJ9644<11y�,V
Address S SPOW I-JAy f 0&_)1 C"
Address / S SO&Qft< C_/M t C/'I
Telephone#
SD8 q-32- -5-5'6S
Telephone# f6e q -,3Z SS -6S
Type of Building fl JJ Lj-L t fUS Lot Size 13, G8 O sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building
Other Fixtures
No. of persons Showers ( ), Cafeteria (
Design Flow (min. required) 44 gpd Calculated design flow W tS Design flow provided 4 gpd
Plan: Date 44/1-7 Number of sheets l Revision Date
Title S! %C- Ru4^' Fo,( PkoPos(1�9 coA-51 tycV oA.,
Description of Sbil(s) SEC �LA'y
Soil Evaluator Form No. +- Name of Soil Evaluator P . N0.3 u N Date of Evaluation 3/(//-7
DESCRIPTION OF REPAIRS OR ALTERATIONS
vM 0 C r%4n 13
S ^144i94iz \f" (A.- (-i LT /1A Olzy "1,_s .
The underrsigne ees to installve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furtherer ees to t top e s m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date f
Inspections 7
No. !tA_] + 41r �i 6:- "I - ire- 1 7
.00
��COMMN�LT14OFM SSAC ET
Board
of Health, , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (+r), Upgraded O, Abandoned ( }
by e ` w Ar i c..t..c ,r -t� ,Pa e'_ N)S-Iao czaj
at a f C!/1. r 0?,
has been installed in accord a e with the provisions of 310 CMR 15.00 (Title 5) and the pproved design plans/as-built plans relating to
application No., " dated Fl r - 7 Approved Design Flow(gzd)
Installer
Designer: D k P\„ S RM �-_ AtJ Inspector:
The issuance of this permit shall not be construed as a guariee that the system will function as designed.
No. _),, ,-. -7~^ 4 n o A. 5Pe%xHk—(-'3 (' 6f4 )-ffi_ , FEE
17- /COMMONWEIALTH OF MASSACHUSETTS de,4110 89 5
Board of Health, V
AIUA n 6 1'C1+ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
as described in theapplication for
Disposal System Construction Permit No. -..... 47�-' dated_f
Provided: Construction shall be completed within e date -of this p mit. All local conditions must be met.
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4+ FFoorrm1255ev.5/966 AM.Sulkin Chale n, MA t Date• pa�rfd of ealth
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