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'l-.Ol°llMONWEALTl�rJt� OF 1' ASSA'1,t1t�l SE TS
Board of Health, 1!Q, MA.
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i L.DITZ-1S-00Y 361
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construc Repair( OUPgrade Upgrade( - b- mPIete System ❑ Individual Components
Location
Owner's Name
lEa�
Map/Parcel# a
Address ./Y
Lot#
Telephone#
Installer's Name nJ
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Designer's Name s-
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Address
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Address 2C__5
'
Telephone# o r R
3
Telephone#
Type of Building _
Dwelling - No. of Bedrooms
Other - Tvpe of Building _
Other Fixtures
Design Flow (min. r quire
Plan Date—1
Title ��/��/
Description of Soil(s) _
Soil Evaluator Form No
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria
gpd Calculated design flowqqQ_ Design flow
Number of sheets _ Revision Date _
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of T= 5'-and
further a not to piac the system in operation until a Certificate of Co pli ° ce has been issued by the Board of Health.
Signed Date -
" Inspections
No.. &o-iC-kc, ._7- 7lam FEE �° /l G� . iac�
� 1 COMMONWEALTH OF MASSACHUSETTS
Board of Health,
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) complete System
The undersi ned hereby certify that the Sewage Disposal System; Constructed^ Repaired ( ),_Upgraded ( ), Abandoned
by: V�/ <(' N) i s""
at �
has been installed in cordaTice with the rovisisns of alo CMR 15.00 (Title 5) and the appr design plans/as-built plans relating to
application No. ��: -- dated / !~ Approved Design Flow um
Installer �r 01-1.;, , C-40 1 13 H` Yt. yrt
Designer: .p�f ��Q� Inspector: { `-Date:
The issuance of this permit shall not be construed as a, guarantee that the system will function as designed.
3 COMMONWEALTH OF MASSACHUSETTS
Board of Health, yk
VM50-If , MA.
FEE, ! W . 00
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DISPOSAL SYSTEM CONSTRUCTIO T PERMIT
Permission is.herebygrantedto; ConstructRepair( ) Upgrade( ) Abandon( ) anindh dual sewage disposal system
at ;� % 1 L C tse C'sn n C �tJf : we as described in. the application for
Disposal System Construction Permit No. dated'" _ 0
Provided: (construction shall be completed withinof the date of this permit,, All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co: Chaileslown, MA Date '1 r f -� r Board of Health