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Cgs /7-7 COMMONWEALTH OF MASSACHUSETTS
Board of Health, Y4'-P,&,oL04 MA.
FEE'
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( AbandonO 9'Complete System O Individual Components
Location I Lt1
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Owner's Name cr /) vj
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Map/Parcel#
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Address I Ll % r24-1111- e
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Lot#
Telephone# go 8- 1 d-9
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Installer's Name
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TI-eA
Designer's Name ® L,
Address a 3
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Address 9
Telephone#
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Telephone#
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Type of Building .F(914 Lot Size sq. ft.
Dwelling- No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers O , Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date �- �_�� Number of sheets Revision Date
Title
Description of Soils) S fy S O i I la
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF`REPAIRS OR ALTERATIONS e �i7 +� �? Si �tti►
Date of Evaluation XL —Z -7 --
DESCRIPTION
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The undersigned agr to'• tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t to, ce °er 'on until a Certificate of ontpliah e has been issued by the Board of Health.
Signed , y Date
3
Inspections
No.y0 c^t`�Q°� FEE 51
COMMONWEALTH OF MASSACHUSETTS (,V/,k r
Board of Health; MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ff Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )'
by:,^1
at aR ) ac to cc r 1 /r� /,n r vi •7`A r C-4
has been installed inccordance with the provisions 0,£310 CMR 15.Ob (Title 5) and thea roved design plans/as-built plans relating to
application No. 1/9-07, dated f Approved Design Flow 7(gpd)'
Installer f \` i -t "j s
Designer: rc .9 l h j A-PhiVelyor: Date:
The issuance of this permit; shall not be construed as a guarantee that th system will function, as designed.
No.
W" 1'7 -7 COMMONWEALTH OF MASSACHUSETTS
r Board of Health, �a i, MA.
DISPOSAL SYSTEM CONSTRUCTION. 'PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (--rAbandon ( ) an indh iidual sewage disposal system
at t i t: t_+ :2 - ,. 'E ;-1 - as described in the application for
Disposal System Construction Permit No. / >I dated' i
Provided: Construction shall be completed within three years of the date of this P rm All localUcondi'ons must be met.
t� �r—isv
Form 1255: Rev. 5/96 A.M. Sulkin Co: ChaBeslown, MA Date pQr � ✓ � Board of Health
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