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COMMONWEALTH` OF �IASSACHUS&TS
Board of Health,1146 KUU I H HEALTH
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APPLICATION FOP, DISPOAM , 'C:�2't!'�I!IS �U CTIO PERMIT
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Application for a Permit to Construct( ) Repair( ), Upgrade Abandon( ) - ❑ Complete System'AlIndividual Components
Location
Owner's Name
Map/Parcel#
Address S'
Lot# 19'
Telephone#
Installer's Name ��' e
Designer's Name
Address / �) C v C Grl�,i+�
Address %�� 41 ��1 r �G✓l
Telephone#
Telephone# ,1/ 7 Z 9 71 Z
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow 3.?b Design flow provided 1 S 7 gpd
Plan: Date 2- `� —a 6 Number of sheets '!"" Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
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Name of Soil Evaluator Date of Evaluation / /?- Vp
DESCRIPTION OF REPAIRS OR ALTERATIONS /
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The undersigned agrees to install the above describe4Individual Sewage Disposal System in-accofdance with the provisions of TITLE 5 and
further agrees to not to place
th to in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed %�Lo/�1/' �" Date
No. L
- Description of Work:
The undersigned hei
by:
at /
has been installed in
application No.
COMMONWEALTH Of MASSACHUSETV
Board of Health, , MA.
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CERTIFICATE OF COMPLIANCE TP i*r > b- x3, ZPa4e�
07Individual Component(s)
b certify that he Sewage Di
DElComplete System ice%
>al System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( )
orda/nce with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
ramc, dated 7 Approved Design Flow.-3 47(gpd)
Designer: Dc// Pn file c! Inspector:! fh �y%�''� Gk��f Date:
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.
-- No. /c;) �T FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, d'P , MA. PUWI/j,
DISPOSAL SYSTEM CONSTRUCT ®1V PERMITL�
Permission is hereby granted to; Construct( ) Repair(=( Upgrade( ) Abandon( ) an individual sewage disposal system
at �/� �(� �C C' J _ as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within:a= o the date of this per it. All local cond' 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health