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No. D� 111- V 0O 13 $ FEE' J+
Board oflealth, p� , MA.,.�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair {Upgrade( ) Abandon( ) - ❑ Complete System 4dividual Components
Location , `
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Owner's Name hk C
Map/Parcel#
Address
Lot#
(�
Telephone# a 0a0i
Installer's Name
SW� `/�
Designer's Name
Address -�
0 4
J
is
Address
Telephone#
r _.
Telephone# S� _
Type of Building is ��Ch -t-: • �CC7t1�. Lot Size 12600 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder(
Other -Type of Building No. of persons Showers( ),Cafeteria(
Other Fixnn•es
Design Flow (mien.. required) of d gpd Calculated design flow Design flow provided � gPd
1 Plan: Date 0 1 i l l % Number of sheets Revision Date
Title
Description ofSoil (s) Me S�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
S'�C� Ct-�.� Ci`n.Cnr�C7c�5 W / -S �y✓vL ,� l��C � 1 . '� x �. �� C.Ik�w
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �h x _ Date C j (te,
Inspections
r
E
COMMONWEALTH Of ASSAC14U E - -
Board of Health, YA12A0 LYN MA.
CEDTI1ICATF ®U COM I TANCIV
Description of Work: Individual-Component(s) ❑ Complete System y, 5" /
The undersigned:hereB certify that the Sewage Disposal System; Constructed ( ), Repaired V, Upgraded ( ), Abandoned ( )
by: rA
at E l r_ S. ,. < < c Rd
has been installed it
application No.
Installer 1Z, r r N
Designer: V , -►k E
The issuance of this
with the ov'.1 1 310 CMR 15.00 (Title 5) and the ap�lroved design plans/as-built plans relating to
dated.Approved Design Flowi 1 U (pd)
permit shall not be.construed as a, guarantee that the system will function as designed.
No. C xl - � p -° o l '1 i r?-i � -. FEE
COMMONWFALT14 Of MASSACHUSETTS
Board of Health, ) MQOT)� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERNIIT
Permission is herebygranted to;, Construct( ) Repair(Lif Upgrade( ) Abandon( ) an individual sewage disposal system
at l i C c..o $ S� nM� F 1� €1,�,.� d..-ii�,. as described in the application for
Disposal System Construction Permit No. '". dated f
Provided: Construction shall be completed within tla-F othe date of this er nit. All loc nditions must be met..
_ Form 1255 Rev. 5196 A.M. Sulkin Co. Chaileslown, MA Dates t W
`Board of Health
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