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Board of Health, Ty, &9M \M4 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair4pgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 7 14l'o-L /4v&
Owner's Name Co-ro( 1464-C'1SQl\
Map/Parcel# d S. q
Address 7 O 6j h delle LO, Vo_r,,,,"7k_
Lot#
Telephone# SW -3V- O F, 76
Installer's Name R06`T- `, Oc�r
Designer's Name.
Address ZN 6v-&_+weAejw 9J, Hd ro i uk
Address
Telephone#SA-50- 1-0
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building
Other Fixtures
Design Flow (mina required)
Plan: Date
Title
gpd Calculated design flow
Number of sheets
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Description of Soil (s)
Soil Evaluator Form No. Name
_ of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS &Pta W— /t WV1 I f re_ 1 � iii CaS`i ErOIN gU ri
0i xylel- Ck
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,p ce thpe system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed(,IOtI CO_;,t06 Date W 27-19
Inspections
No. ii FEE 00
Board
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �Y.�#2..Yy 0 t �►t �T'A , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ®/Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired 4- Upgraded ( ), Abandoned ( )
by: to, :t,"C.
at ' 7 144 l ex h Agee
has been installed i accordance with the provisions of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. .�s� dated "?' Approved Design Flow (gpd)
Installer F
Designer: Inspector: ,0' Date: �- d[✓ �e°7�
The issuance of this permit shall not be construed as a gua tee that the system will function as designed.
No. f21D4A X) C. 'I Q = 1 t l Z,. C.e�, FEE _ aco
/ C®�l[I� ONWEALTH Of MASSACHUSETTS
Board of Health, VAM QMA MA.
DISPOSAL SYSTEM CONSTRUCTION _PERMIT
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at f ���� Ave as described in the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within 4A 4,qrs of the date of this permit.,All local conditions rp.iist be met.
Form 1255 Rev. 5/96 A.M.SulkinGo. Chadeslown,MA Date rs! _f Board of HealthZ:�&