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FEE �l0t00
CO-14MONWEALTH OF MASSACHUSETTS J& 09(0(Z
+' Board ofllealth, )6ggMO(J'T t , MA. RECEIVED
DATION FO - ISPOS L SYSTEM CONSTRUCTION R 19 2018
Application for a Permit to Construct('
Repair( Upgrade( AbandonO Complete System 0 Iti viduNptfpT
Location 5 SU msx---tOwner's
Name
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Map/Parcel#.- '
Address
Lot#
Telephone#
Installer's Nam / d,� .71412
esigner's Name ' `'
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Address y
Address 1 _
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Telephone*3W
Telephone#a-
Type of Building � P/t
Dwelling- No. sof Bedrooms
Other - Tvpe of Building
Other Fixtures
Design Flow (min
Plan; Date
IS -
Title
Description of Soil (s)
Soil Evaluator Form No. _
_ Lot Size 9 7/a sq. ft.
Garbage grinder(
No. of persons Showers ( ), Cafeteria
gpd Calculated design flow_ Design. flow provided gPd
Number of sheets Revision Date
i
Name of.Soil Evaltam d- Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS f �s E/=—
��_s
(Individual, Sewage;' Disposal System in accordance with the provisions of TITLE 5 -and
s until a Certificate of Compliance has been issued by the Board of Health.
Date
Inspections
?bI
:f
COMMONWEALTH OF MASSACHUSETTS 01- FEE
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Board of Health, YA(ZM00TH , MA.
CERTIFICATE OF COMP 'LIANCE
Description of Work: ❑ Individual Component(s) ®'complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaircd ( ), Upgraded ( )> Abandoned
at
has been installed i acc rdance with the provisions of 3 CMR 15.00 (Title 5) and the • proved design plans/as.-built plans relating to
application No.�-` dated% Approved Design Flow��(gPd)
Installer i
Designer:! 4 � l��"�' ! Inspector: ate:
The issuance of this permit shall nit be construed as a guar a that the system will function as designed.
No. , ", i �t ' ��� j }"� FEE ,
.� 74 COMMONWEALTH Of MASSACHUSETTS
Board of Health, YA 0 (%`r , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission ishereby granted to; Construct Repair( Upgrade (.) %Abandon an individual sewage disposal system
}
at 1 ~. `� t� tit �� t `° r� f 1�1 �s l� _ as described in. the application for
Disposal System Construction Permit No. ? dated �- r
Provided: Construction shall be completed within thfeF ars of the date of this per t. 111 on ' 'o s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co: ChMeslOWp, MA /ate fdBoard of Health