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�y No. O 19 0 d 1 -79-0 �l
COMMONWEALTH OF MASSACHUSE TTS
/ Board of Health, XAT \+�4 , 1VIA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair( ) Upgrade4-<Abandon( ) - , omplete System ❑ I
FEE_
Location42 �S
Owner's Name.
Map/Parcel#
Address fI' �.
Lot#
Telephone#
Installer's Name
Designer's Name hci
Address -_
Address
Telephone# 5: p� —
Telephone#
Type of Building/ GI'1%� Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder(
Other - Type of Building No. of persons Showers O, Cafeteria ( ).
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of.Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS5�— /5�wo 6$L /I _
The undersigned agrees to ' tall A�abovede d Individual Sewage Disposal System in accordance with the provisions -of TTTI E 5 and
further agrees to no to a the don until a Certificate of Compliance has been issued by the Board of Health.
Date Signed `�
Inspections
No.
Description of Work:
The undersigned hej
bv:
at C i
�e_
FEE
COMMONWEALT14 OF MASSAC14USETTS
Board of Health, VA2AO QDA MA.
CERTIFICATE Of COMPLIANCE
Individual Component(s) Complete System
p�certifyrthajtnthe Se)vage,DisDosal stem; Constructed O, Repaired (VY, Upgraded ( ), Abandoned ( }
has.been installed in accordance with the provisions of 1.0 CMR 15.00 (Title5) and the approved design plans/as-built plans relating to
application No. , dated . Approved esign Flo (gpd)
Installer A o,_JZOr� )-1 �h-e"�j s� at �- P'sne"r` �P
Designer:. .. �� (Jt%[�rt_ Inspector: ( z Date: f ��
The issuance of this permit shall not be coonstrued as a guaran ei a that the system will function as designed.
No. �,/� '� �� / FEE
Of MASSACHUSETTS rG
Board of Health, \�1i1 , MA.
" DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(t,) Upgrade( ) Abandon( ) an individual sewage disposal system
at R �lILI as described in the application for
Disposal System Construction Permit No./j `-�" , dated
Provided: Construction shall be completed within .l] rs of the date of this ern#it. All local condip ns must be met.
Formf1255 ev. 5/96 A.M. Sul,+kin Co. Chadeslmvn, MA �{ Date and of Health y /t
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