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No. �` c oo _[ C.i � � !�/ Al~ FEE y l J
8040 �
COMMONWEALTH OF MASSACHUSETTS r�0�`�8�
Board of Health, MA.
r ?/M
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct() Repair( Upgrade Abandon( ) -Complete System ❑ Individual Components
Location
UP
Owner'sName
A t r 1� C C
Map/Parcel# bo
a l7
Address , A0
16 S Rd. s® YA(-AAU v1 ) A/�, "
Lot#
Telephone#
Installer's Name��
I-� Grp '1
Designer's;• Name
��.��
e4p )�
Address
,% • �a
is AR► VJ\
Address
Telephone# d
— L
Telephone*
—
Type of Building Lot Size 47, q, i 5JQ sq. ft.
Dwelling -No. of Bedrooms arbage grinder {
Other -Type of Building No. of persons Showers O, Cafeteria
Other Fixtures
Design Flow (miMed) 1 Q gpd Calculated design flow Design flow provided �: gpd
Pian Date �L6 Number of sheets 3 Revision Date
Title
Description of Soil (s) is H O 1Z N S LQ Alk',-qh o r) zc) we ' fJ
Soil Evaluator Form No, Name of Soil Evaluator
Ann (/t?i) 140A'P, Date of Evaluation I r -)a —13
DESCRIPTION OF REPAIRS OR ALTERATIONS
(s) e a S OCC110toC��ti�vlrel �`S
The undersigned agrees to installthe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to a the sys a in operation until Certificate of Compliance has been issued by the Board of Health.
Signed Date
d
No. FEE
COMMONWEALT14 OF MASSACHUSETTS).,PX'�%� r `'
/Z
Board of Health,;. , MA. �t�l r.
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) ®-C-0-1Mplete System
The undersigned hereby certify that the Sewage Disposal System; Constrgucted O, Repaired (' ), Upgraded\�<, Abandoned ( }
by: o u Or.
,.
at r ✓-/f% ��
has been installed in accords ce with the provisi s o&410 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. L dated `' _. Appyoved Design Flow Zgpd).
Installer 00, R, Ct^s_7 I -r }r
Designer: l)+L-)�g Ki t�M C ` Po
The issuance of this permit shall
0 -ft , , nspector: ,/-i r r Date:
be cons tru as a guara"e that the system will function as designed.
FEE .. 5 0
COMMONWEALTH OF MASSACHUSETTS ck--W 09887
Board of Health, YA-a4movIA MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system
at \j G1 �, I o S {r��.�fC l as described in the application for
Disposal System Construction Permit No, "'3'-%` 7 `` , datedr N�`
y
Provided: Construction shall be completed within tl U,' the date of this permit. All localccgiditions must be
Form 1255 Revi'5/96 AM. Sulkin Cq'. Chadegowny, �Cyp Dated rr'� Board of Health P&/_ �