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No.� �� —f8� / / Z //�j,`//.d /� FEE'
1 70
d.� C®MM®N�T L,TIT Off' MASSACHUSETTS 0'70 It
Board of Health, Q(_, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRU m ]PERMIT'
Application for a Permit to Construct() Repair( UPgrade!'�/Abandon ❑ Complete system VindividuaCom onents.
Location
ad 15 446► R14-4
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
f t
Designer's Name 90-1 /
Address/7
9 `94 V { � 1 � � t � UVB ,
Address 441- z. � � - t/✓�e'✓ -
Telephone#
qJ0 ,, 4U5
Telephone# 5-0 Z
Type of Building - _ Lot Size _ sq. ft.
Dwelling - No. of Bedrooms Garbage grinder(
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow . � Design flow provided _ Y,5. 12 gpd
Plan: Date ��` / �� ` Number of sheets Revision Date
Title
Description of Soils) i-ce
Soil Evaluator Form No. Name of.Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS Gl,� J
Date of Evaluation // - % ` 19-
07
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 Zoace e m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
rr
No. •1) �L �`(:l "T �)�i U✓'�''/ FEE �.
COMMONWFALT14 OF MASSACHUSETTS
j Board of Health, Ill\ , MA. d•
CERTIFICATE OF COMPLIANCE
Description of Work: 9Individual Component(s) O Complete System
The undersigned hereby cerpfy, that the Se age Disposal ystem; Constructed( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: t j -e /A' 16
at
has been installed i ac or nce with the provisions 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated �/� Approved Design Flow (gpd)
Installer
Designer: �� aw / Aael� Inspector: Date: c�
The issuance of this permit shall not be construed as a guarantee that W11system will function as designed.
No-6��i'.7E st� �(...t�'` i i FEE li
- , COMMONWEALTH Of MASSACHUSETTS
Board of Health, o n MA.
DISPOSAL SYSTEM CONSTRUCTION- RMIT
Permission is hereby grand to Construct( ) �Rjepair ( ) Upgrade (Abandon ( } an individual sewage disposal system
at � � � 7�� "' `'` % ��" , as described in the application for
Disposal System Construction Permit No/ dated
S
Provided: Construction shall be completed within th-ree-�y4GaTrs of the date of thi pe t. All local coj4ditions, must be met..
Form 1255 Rev. 5196 A'M'
Sulkin l Chade n, MA -Date/--3/ ^ / I Board of Health 's