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App-Permit-Compliance
No. ITI FEE C®MMONWEALT �� � ������ CV0//IIE Board of Health, 2 e ";;, ( :(.)`s' MA. APPLICATION FOP, D1 POSAL"SWf&"e0*WfTION PERMIT Application for a Permit to Construct( ) Repair (a ) Upgrade( ) Abandon( ❑ Complete System XILilidual Components Location S u S -e— RP Owner's Name Map/Parcel# /i7 Address Rip Lot# Telephone# Installer's Name E Designer's Name Address VVt Address Telephone# Telephone# Type of Building 1 ` cs (tq`,V�` W" _ Lot Size Dwelling - No. of Bedrooms Other -Type of Building No. of persons Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil (s) Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator sq. ft. Garbage grinder( ) Showers ( ), Cafeteria ( ) Design flow provided gpd Revision Date Date of Evaluation The ersi d agrees to tsthe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furth of to plasystem in operation until a Certificate f Compliance h been issued by the Board of Health. Signe Date Inspections No.y/ FEE /V L� V COMMONWEALT14 Of MASSAC14 SETTS 7 l gill Board of Health, o u' Kit , MA. CEPITIFIC COMPLIANCE Description of Work: Ill ndividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage isposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( ) bye V t G at U 14 jam- © 0 CA has been installed inccord n e with the rovi ' ns of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated / Q Approved Design Flow (gpd) Installer `1 11 Designer: – Inspector: VK L1, 7`7 Date: (` IV The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. FEECOMMONWEALTH Of MASOACHUSETTS J�1 Board of Health, V A,11 0 DISPOSAL SYSAMPNSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair ) Upgrade ( Abandon ( ) an individual sewage disposal system at U S-A (a?-& `( LX_ �/� V Aoa 4,R 0 cq1 ' d as described in the application for Disposal System Construction Permit No. rJ ' �� dated 4- 2C1 re�g Provided: Construction shall be completed within three years of the date of th�ismit. All local conditions must be met. �d U ` / Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date � Board of Health