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/7— // , PMMONWEALTH OF MASS CHUSETTS �58�0
Board of Health, A/ "UT14 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( Complete System ❑Individual Components
Location
Owner's Name
Map/Parcel#
AddressT!tj
Lot#
Telephone#
Installer's Name
Designer's Name sojee
Address
Address
Telephone#
I Telephone#`—
Type of Building _ Ajoy
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size Q sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated des I
n flow Design flow
Plait: Date 5rl Z-7� Number of sheets Revision Date _
Title
Description of Soil(s) See P\w'Y\
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 6$ F&T1
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further aye t to V.e system in operation until a Certificate of C pit ce has been issued by the Board of Health.
Signed Date
,ktwpections
a
No. 60 4,9 �' 1 � "� �J ata FEE 't`
f COMMONWEALTH OE,MASSACHUSETTS �. 5e3-7
r A —7 Board of Health, �Ti1-� , MA.
CERTIFICATE OF COMP IANCE
Description of Work; ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired ( ), Upgraded ( ), Abandoned ( )
by: (2- L— �X C f-A V —
at r
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
application No.. %f �!�� dated A / ;I -"f 7 . Approved Design Flo (gpd)
Installer
{ �
Designer: .Pd'4f�t �t� �,v-, � - Inspector: �'i�--= Date: � 1 �d
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. I,i s� ? - t i ia.J� ('tl�,` , FEE o, 00
COMMONWEALTH OF MASS CHUSETTS 9 7 �
Board of Health, �(tl , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permissioil is hereby granted to; Construct Repair ( )' Upgrade ( ) Abandon ( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. P' , dated. f "-f` 7
Provided: Construction shall be completed within ars the date of this permit. (,.All local conditiqns must be met.
Form 1255 Rev.5196 A.M. Sulkin Co. Cha stown, MA Date '� I' Board of Health r