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COMMONWEALTH OF MASSACHUSETTS
Board of Health, �u:uf , MA.
APPLICATIO V FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
LocationOwner's
Name����' T
Map/Parcel#
!
Address —1-2.��
Lot#
Y 3
Telephone#
Installer's Name
Designer's Name
Address
d4
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS`"� —:5-e
e /V=2r� AIIJC
The undersigned agrees to ' stall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not Ktpace the min operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
_.00A
No:
COMMONWEALTH EALTH O MASSACHUSETTS FEE
Board of Health,
CERTIFICATE OF COMPLIANCE (,.�/-e7T
Description of Work: Q4!ff ividual Component(s) ❑ Complete System C)
The undersigned hereby certify that the Sewage Disposal System; Constructed (� ), Repaired (-- Upgraded ( ), Abandoned ( )
by: /? C, --a Ce,
at 4Z 90 14,1 V C, f /2 / 4d
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. Odated Approved Design Flow "^-' (gpd)
Installer /1 1
Designer: Inspector:
The issuance of this permit shall not be construed as a guarantee that
Date: �' 1�� ��✓
system will function as designed.
No.v a 30C ��(�/� �T�(�TL ¶� 1�(�T FEE
SETTS
Board of Health, �-✓ �^�"` MA �'
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at '/-9- QAz42CsZ 4 ae V-1 b6+ as described in the application for
Disposal System Constru--ction Permit No. dated
Provided: Construction shall be completed within three years of the date oytpis permit. 411 local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �/ �-- Board of Health -61 1 C�