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COMMONWEALTH OF MASSACHUSETTS
A $, 3 i 7"019 Board of Health,OOT-0 , AVIA. ( OO Lfq L( 1
HEALTH ION FOR DISPOSAL SYSTEM CONSTRUCTION PE%mrnponents IT
:ion f r a Permit to onstruct( ) Repair( grade() Abandon() - ❑ Complete System ❑ ivv
Location I
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Owner's Name
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name AllQW
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Designer's Name
Address
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Telephone#
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Telephone#
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Type of Building &Z ?
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size j1r U0fD— sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria ( )
Other Fixtures w
Design Flow (min. required)) � '"y /U gpd Calculated design flow 3 3 Design flow provided gpd
Plan: Date 3� ( Number of sheets Revision Date
Title �11a dd 3-t^� �f.�'�a"1�� V t SFt/> 0
Description of Soils) 0-17— WOOL Jr e2 - 3 (e r �,on•rl , 3 G �� 08 o
Soil Evaluator Form No. Name of Soil Evaluator Vid 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 o nol to�ce the tem in operation until a Certificate of omp nce has been issued by the Board of Health.
Signed % 4 n/ u/G-'^-� Date 3 r I1
Inspections
No. C� 4� �C { U FEE Y' • 06
COMMONWEALT14 OF MASSACHUSETTS
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Board o Health, �1(L1 b10 urm , MA. / r f C• ( �► "" r ,
CERTIFICATE Of COMPLIANC��
Description of Work: lti Individual Component(s) ❑ Complete System
The hereby undersigned that the Sewage Disposal System; Constructed"
g y certi fy t ` g p y O, Repaired (, ), Upgraded Abandoned(
has been installed i cco ante with the prov7si ns of 510 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer 4 ' t l 1 rN C( f
Designer: 94 N 6,o 4 r C-. Inspector: pate:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, )kq-mo UTA# ,AVIA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; /Construct( ) Repair( ` - Upgrade ( ) Abandon ( ) an individual sewage disposal system
at / t.-
%" ' :^ t ; "t v,' t��'` / as described in the application for
Disposal System Construction Permit No. j 7 '"17 , dated ,.e-- 7/f
Provided: Construction shall be completed within 't�s oflthe date of this All local co 'tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date "loard of Health 6-14 L'
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