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No. e700C."' C 1—ZJ! 5 g (./Y/TF-,r 19 — 0 `i C[\--)' FEE12-
COMMONWEALTH
2-
C®MMON LTH Of MASSACHUSETTS 465-. 00
Board of Health, l 9�e.i1 o(JN , MA.
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application r a Per it to .Construct( ) Repair( ) Upgrade Abandon( ) .feinplete•System ❑ individual Components
LocationJ?Q LZ
tW Owner's Name
Map/Parcel# C
Address
Lot#
Telephone# 7 711-8 76- G q0 j
Installer's Name r��/L En
O✓1 Designer's Name s wtd�StT e.rw
Address PC) 00k %
__ ...
Address -lG3 .f ockc4 IT
Telephon e# 7 )G ' CyL O
-!roe-�j�y..
_ Telephone# 'Ue_ 3st S- 6400
Type ofBuilding Of Se,A'<' Lot Size I I eiy6 • 9 sq. ft:
Dwelling -No. of Bedrooms�rk/cc _ Garbage grinder (
Other - Type of Building No; of persons Showers O Cafeteria(
Other Fisttnres 77
Design Flow (min. required) �J D gpd Calculated design flow Design flow provided 3Sl gpd
Plan:' Date 10 J& Number of sheets _ 1 Revision Date
Title
C �r _
Description of $oil(s)'.y1' Sf� L 1,-
s a - 'i(ff w�Ai,Vrn ._l'c.. P1
Soil Evaluator Form No. Name of Soil Evaltnator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 place the system in operation until a Certificate of C mp ' "ce has beenissued by the Board of Health.
Signed _ Date f
Inspections
No. C t L�- ...1 ! G'W /fr
��NI®NS IFEE
OF AS
Nl['
Board of Health, �Y .>�'�OVV , MA.
CERTIFICATE Of COMPI.IANCE
Description of Warks ❑Individual Components) omplete System
The undersigned herebycertify that the Sewage Disposal System; Constr acted ( ), Repaired ( ),Upgraded (o4"7Gandoned {
by K i k Cr / ,. ^ g1 [4 7 c f rte' c /, •r �.
1:
lk
has been installed i actor ance with the ro�ris rt5 of lU GMR 15.Q0 (Title 5) and the :approved design plans/as-built plans relating to
application No. dated. Approved Design Flow%3 (gpd)
Installer 0.
Designer: Inspector Date: '
The issuance of this permit shall not be construed as a tee that the system: will function as designed.
21
No. U C � . -2 q} 0i l-- FEE'
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y&?=n1ZiLM4 , MA.
DISPOSAL, SYSTEM CONSTRUCTIQN PERMIT
Permission is hereby. granted to.; Construct( ) Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
at as described in the application for
�, Disposal System Construction .Permit No. dated.. --7- i r ''
Provided: Construction shall be completed within three years of the; date of this erm t. All local onditions must be met.
ti
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadegown, MA Date'- !r Board of Health
A 94�