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�� Board of lkalth, MA.
PP CATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Appl cat o`rs. erm't to Construct( ) Repair( ) Upgrade(j.�AbandonO - 906omplete System U Individual Components
Location
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
j Designer's Name
Address
Address
Telephone#
Telephone#
Type of Building ,A 66XI IML, L, 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) 0 gpd Calculated design flow ~ i CA. Design flow provided 35S e d
Plan: Date A0j4,V01 f Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of.Soil
DESCRIPTION OF REPAIRS OR ALTERATIONS
Evaluation
Theun si ed agrees t tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furtheto Igce operation until Certificate o C� li eeu issued by the Board of Health.
Signe dr Date
/
vi /�_tlss
No. COMMONWEALTH OF MASSACHUSETTS �
_ Board of Health, 0 M4 , NIA. _e)
!CERTIFICATE Of COMPLIANCE
Description of Work:; O Individual Component(s) &,(• Implete System
The undersigned hereby certify that the Sewage Disposal Syste ; Constructed ( }, Repaired ( ), Upgraded (Abandoned ( )
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by: { f �� � �ra
at
has been installed�il()
ccord gee with the provi, ons 310 CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to
application No. +�f dated ` f r/ Approved Design Flow�Installer '' 1 !' . C 1�:. �` 7 �. � � . � � ���f 1 � I : C i�- ' 1\4 C �✓
Designer:': 1 c�'/ Inspector: L) �� Date: r + r
The issuance of this permit shall not be construed as a guaran a that the system will function as designed.
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No: 112- 'r FLE .
COMMONWEALTH Of MASSACHUSETTS
Board of Health, ) AAgmoyr-4 , MA..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;; Construct( ).Repair( ) Upgrade (VAbandon ( ) an individual, sewage disposal system
at �� ` d'� a)iTf 7 - P f_ 5T a. - p� 0 as described in. the application for
Disposal System Construction Permit No., dated 6
Provided: Construction shall be completed withinars of he date of this pert •t. All local ondituiops must be met.
Form 1255 Rev.;/96 A.M Sulkin Co. Chadestow '. •�
A s Date�" (,y, Bo/acrd f Health �. r