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Board of Health, VAc&oo-ni MA.
APPLICATION FOR. DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair�6pgrade( ) Abandon( ❑ Complete System 0 Individual Components
Location 3
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Owner's Name (#,uq, to rAwc Co Ve-c
Map/Parcel#
0'3 a . t Q e
Address n ':54r—r Ln .
Lot#
Telephone# 5697'— 3(TL — yo58
Installer's Name !J
Designer's Name.
Address 2H
�f n
Address
Telephone#"�
�44tA,
Telephone#
Type of Building
Dwelling No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (mina required) gpd Calculated design flow
Plain: Date Number of sheets
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS R q1C%4e- A _ 6v x a^ J` x�h s+c— u 93e r
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreeston t to place e s tem in operation until a Certificate of Compliance has been issued by the Board of Health.
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Signed �U�' ✓Ao 11 B X CQ9� �� Date 11' 7 —J O
(Inspections
No. Qtk {-j 7 ' FEE :.
COMMONWEALTH OF MASSACHUSETTS,
Board ofHealth, , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: VIndividual Component(s) 0 Complete Systeme
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ('Upgraded ( ), Abandoned ( )
by:
at
has been installed accord a e with the rovisiorl of W CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. f dated , . Approved Design Flow °� (gpd)
n
Installer
Designer:--'"'~"p Inspector: ,�.� C.t> Date: _
The issuance of this permit shall not be construed as a guarantee that a sy�fem will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board c f Health, ` a'j o i -mi MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
FEE
d
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an indhidual sewage disposal system
at
^� as described in the application for
Disposal System Construction Permit No.f '" / dated � .
Provided: Construction shall be completed within th* of the date of this perm t. All local conditions must be met.
Form 1255 Rev. 5/96 A.M.;Sulkin Co. Chadeslown, MA Date _ Board of Health