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COMMONWEALTH Of MASSAC14USETTS CW-703y
Board of Health, yAamo11-4 , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ❑ Complete System
AdividualnComponents
Location
Owner's Name
V h
Map/Parcel#
Address��
Lot#
Telephone#
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Installer's Nam/ r
Designer's Name
Address l ?&V ✓ / %L
Address
Telephone# ` % s-
Telephone#
Type of Building //( Q��C�Lot Size sq. ft.
Dwelling - No. of Bedrooms 2 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( ).
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided _ gpd
Plan: Date 2-0 O- Nurnber of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRI
,yj�_QN OF REPAIRS OR ALTERATIONS
Date of Evaluation
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 syste tion til a Certificate of Compplian has b en issued by the Board of Health.
Signed Date
No. 9Y7 FEE 7
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, ,
A CERTIFICATE OF COMPLIANCE —TA fo, 1 i.4 4e,,.
Description of Work: findividual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (, Upgraded( ), Abandoned O`
by: ACC V S�C li E C- T
at 2,Z 1C AW Cl (--S LAJlit
has been installed in accor an on ce with the rovisis of 3.10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated�'/ 4 .- Approved Design Flow """` (gpd)
Installer `'C 1 `� C F} - C 'C -- 0 ^ f U..
Designer: '~""" Inspector: 41f Date: LS
The issuance of this permit shall not be construed as a guariaaree that the system will function as designed.
1 »2./ t i --CQ 5ZE i CJAG0C. FEE
/ COMMONWEALTH Off' MASSACHUSETTS .
Board of Health, � fl4/i n _, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual, sewage disposal system
at -3 �i _ f - (� i %1 c , as described in. the application for
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Disposal System Construction Permit No. dated 0
Provided: Construction shall be completed within t-4 f t& date of this permit., All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date ( WBoard of Health
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