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No.
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, nil.
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APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairK._ Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location o'B ro A,
Owner's Name C'rtLtt,300 3P�✓ <J641 , j 14
Map/Parcel# "L2 ?.� �� Gi Z
^
Addressv'u •q sJ
Lot#
Telephone#
Installer's Name • ►
J + S
Designer's, Name
Address ��.�
Address
Telephone# f �'� f $ --1
Telephone#
Type of Building C� y
Dwelling - No. of Bedrooms
Other -Type of Building
Other Fixtures
Design Flow (min, required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
No. of persons
Lot Size 1,0,oc7+r sq. ft.
Garbage grinder(
Showers ( ), Cafeteria
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees o not to ce the system in operation until a Certificate of Compliance has bee issued by the Board of Health.,
Signed.. Date L
Inspections
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No. FEE ` Nf
' C®MMON V'V' 1LT14 OfMASSACHUSETTS
Board of Health, Tit QQMA _ _ , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 6 l Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( )> Repaired./Upgraded ( ), Abandoned ( )
at L'C3
PP f provisions of 3 0 CMR 15.00 (Title, 5) and the approved design plans/as-built plans relating to
has been installed in accordance with the
application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector: , Date: f_
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. � U �'j E'W 1'1) e FEE
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C7 - f COS' MONWEAI,T14 OF MASSACHUSET S
Board of Healtli, NM 0 t Ink --_ MA.
DISPOSAL SYSTEMCONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair{t j) Upgrade( ) Abandon( ) an indhidual sewage disposal system
at (0 J )A-- , 5 �t � � � � � as described in the application for
Disposal System Construction Permit No. /, dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co: Chadestmvn, MA Date A • 1 : ) Board of Health �i' ` r �• r