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P �,�� ATION FOR DISPOSAL SYSTEM CON TRUCTION PERMIT
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App imtion for a Permit to ConstructO Repair( Upgrade( Abandon( - Complete System O Individual Components
Location Ili
Owner's Name
Map/Parcel#
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Z'
Address 3-L- Wle l0.rKJLLV- _
Lot#
Telephone# --
Installer's Name tCt`���--
Designer's Name LAG
Address &
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Address �IV7 5�
Telephone#�j
aQj • J,
Telephone# & 3 d0
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 •4 qy gpd
Plan: Date Number of sheets Revision Date
Title
Description of S'oil(s) _
Soil Evaluator Form No
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS n' �
Date of Evaluation
The undersign d agrees to install the above described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further agrees not to pla the system m oper tion until a Certificate o om fiance has been issued by the Board of Health.
Signed '� Date J�
' Inspections Z (� �G�LS c ( ��`tAe �7v o
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No. 6KDC-19-29
COMMONWEALTH OF MASSACHUSETTS
Board ofHealth, ld% , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: C3 Individual Component(s)1�h"em Tete System �� ✓� . f
The undersigned hereby certify that the Sew ge.Disposal System; Constructed Os, Repaired ( ),Upgraded..,(
�a
by:
at
has been installe ac ce with the provisions of 10. GMR 15.00 (Title 5) and th approved design `plans/as-built plans relating to
application No. �{�/� dated -:Z . Approved Design Flow (gpd)
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Installer 11
Des igner:,)►.l )LJ,_!jr,ZG
The issuance -of this permit shall
No.
2 C ,11 :.t.b--i-
Inspector: