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COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yew T-7+ , MA.
FEE'
d,664i57q
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( )'Repair( ) Upgrade( ) Abandon( - ❑'Complete System 0 Individual Components
Location: �j�`
Owner's Name
Map/Parcel#
2 , p
0 3 ► ?--0`'i
Address
Lot#'•
Telephone#
Installer's Name
Designer'sName
Address
Address
Telephone#
d 3
Telephone#
Type .of Building' Lot Size sq. ft.
Dwelling - No. of BedroomsGarbage grinder ( )
Other - Type of Building No. of persons Showers ( ); Cafeteria ( )
Other Fixtures
Design Flow (min. required) r 8 gpd Calculated design flow Design flow provided gpd
Plans' Date Number of sheets Revision Date
Title
Description ofSoil (s)' ,.0—"—
Soil
2_ n Soil Evaluator Form No. 4 Name, of Soil Evaluator Date of Evaluation
t
d
The undersigned.agrees to install the above described Individual Sewage;Disposal System in accordance with the provisions of TITLE 5 and
further es to not to place the system in operati until a Certificate of Compliance has been issued by the Board of Health.
Signed. Date
Inspections.
COMMONWEALTH Of MASSACHUSETTS FEE
MMA. I
Board ofHealth, 6�
CERTIFICATE Of COMPLIANCE
Description of Work: ❑Individual Components) ❑ Complete System ��ri,�
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ), Upgraded ( ); Abandoned ( ).
Alp
at /
has been installed in
application No.
Installer
with the provisions Sg310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated ^� _. Approved Design Flow (gpd)
Designer: -- inspector; . Date.:
The issuanceof this permit ;shall not be construed as a guarantee that tl system will function as designed.
No. + M EfZC[ 1-rrr
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, ��D (J %}�` , MA.
DISPOSAL, SYSTEM CONSTRUCTION PERMIT
FEE'_y
Permission is hereby granted to; Construct( ) Repair Upgrade(' ) Abandon( ) an individual sewage disposal system
at �r�.i,�t� �.r� ._~'�2.� as described in the application for
Disposal System Construction Permit No. dated.., 27
57
Provided: Construction shall be completed withinooars f the; date of this r it. All local co dtions must be met:
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown,MA Data.") -+-4Board of Health f: