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No. % a7C
lr- COMMON` ALTH OF MASSACHUSETTS
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION pEjZMftAR 2 2 2019
Application for a Permit to Construct( ) Repair( pgrade( ) Abandon( ) - ❑'Complete System O Indivi ual : Epi'
Location
b Q�
Owner's Name d S �n N A� N�J�-t
Map/Parcel# ��
b 3 �j, 131 $ 'Z _
Address 9 0 X 3tA Z 4-t1 AN/V (j 6_24601
Lot#k
Teleplione#
Installer's Name
-SQ )L LJ �.'C�
Designer'sName
Address
Address
Telephone#
3 ✓ �� "�
Telephone#
Type .of Building'
Dwelling -No. of Bedrooms
Other -Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Lot Size sq. ft.
Garbage grinder
No. of persons Showers ( )_, Cafeteria ( }
gpd Calculated design flow Design flow provided gpd
Number of sheets _ Revision Date
Title
Description of Soil(s)'
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
The undersigned es to install above described Individual Sewage Disposal System in, accordance with the provisions of TITLE 5 and,
further agree of to place a tem in o L eration until a Certificate of Com liarSc s been issued by the Board of Health.
Signed, ih Date
Inspections
—1 -
No.
�- C"� COMMONWEALTH LTH Of MASSACHUSETTS � �i � 2 �l
Board of Health, �a�m0L�TU , MA.
CERTIFICATE Of COMPLIANCE
Description.of Work: _..Lk11-idividual Component(s) ❑ Complete System
The undersigned hereby certify that the Se wa e Disposal System, Constructed O Repaired Upgraded( )> Abandoned ( ).
by:—�<.G��JC �C�" -�-k ('�� 1'� 4`J I� - S b 1 V ��% — )—r-
at . :� f 30
has been installed* accordance with the}provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to.
application No. f 5-Y , dated `7 ' �� F Approved Design Flow (gpd)
Installer
Designer: ---^' Inspector: Date:
The issuance of this; permit shall not be construed as a guaree that the system. will function as designed.
COMMONWEALTH Of SSACHUSETTS
Board of Health, MA.
ISROSI� SYSTEM CONSTRUCTION_ P RMI �
-7—
No.
7-
FEE S.�l
Permission is hereby granted to Construct( � RepairA Upgrade Abandon an individual sewage disposal system
at - 3<3 ��� 1 G� as described in the application for
Disposal System Construction Permit No. I.'/ �,V , dated
Provided: Construction shall be completed within three Years of the date of this `permit. All local conditions must be met.
Farm 1255 Rev. 5/96: A.M. Sulkin Co. Chadestown, MA Date : s r Board of Health
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