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No. �f C-18� - I Q� t�O�-I 3i3
_ FEE
Board of Health, yin , MA. � �U
PPLICATION FOP, DISPOSAL TEM CONSTRUCTION PERMIT �1
/ plicatron for a Permit to Construct( ) Repair( ) Upgrad Abandon( ❑ Complete System 2rti.dividual Components
Location J-6
�i �G)) tClkel
Owner's Name
Map/Parcel#
�Jr'-{
Address
�ijlGl,({ Ccl'f'tti
Lot#
Telephone#
L3d 3 - 0 , 4-1
Installer's Name &tcota,/Ld
Designer's Name Cujq Q&cjinetwlej
Address
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,
M�liAS'�t(JVI !�(-� � Wi,IM. S V[) �
Address
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Vt fk. A YCt f'11�6tt.
Telephone#
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Telephone# (,rvaj(p�.
5� f
Type of Building n Lot Size sq. ft.
Dwelling - No. of Bedrooms i Garbage grinder ( )
Other= Type of Building No. of persons Showers O, Cafeteria ( )
Other Fixtures ,, ll
Design Flow (min. required) I1() 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
The undersi d agrees to install the above described Individual Sewage Disposal System in accordance with the, provisions of TITLE 5 and
further agree o not toeptAhe system in ' e on until a Certificate of C pli has been issued by the Board of Health.
Signed �! �"` Date i� f �.
Inspections ,2 i0�R S0 F -a o lG
a
No. t) ° - 7 ° iZISSd+'`i�' ' /' �� FEE}
COMMONWEALTH OF MASSACHUSETT . .
Board of Health, oC , MA.l�.s ,� ,� " 4j. 100
CERTIFICATE Of COMPLIANCE
Description of Work: 0o'Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System;- Constructed ( ), Repaired ( ), Upgraded Abandoned O'
by: {i,k Ie)E ) 1,k'cl
at "� �f I' o od i-) c
has been installedin'acc
application_ No.
Installer.i, G1c,(
Designer: t L�! ° .t "I
t
The issuance of this permit shall
No
%,,,W,01 (C-)-1 L
Permission is hereby
at
w12ekt pr,"Asi&A 310 CMR 1.5.00 (Title 5) and the approved design plans/as-built plans relating to
dated Approved Design Flow (gpd)
et Y'I(4 Inspector: Date:
lot be construed as a guarantee that the system will function as designed.
FEE i !:� s n o
COMMONWEALTH Of MASSACHUSETTS
Board of Healtic, iJ MA. —is-6—, W
DISPOSAL SYSTEM C®NSTRUCTIOPERMIT CP�� ����
NT
to; Construct( ) Repair( ) Upgrade Abandon( ) anindividualsewage disposal system
as described in. the application for
Disposal System Construction Permit No. dated
�j f
Provided: Construction shall be completed within tlTme Vm rs of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5l9fi A,M.Sulkin Co. ChaaeSlOWn, MA Date BO d of Health
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