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COMMONWEALTH LTH ®f MASSACHUSETTS
r t. 'F; M. -10UTH HEALTH
Board of Health, MA.
APPLICATION ➢�ISP®S. ;� `�TI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon() - ❑ Complete System 16 ndividual Components
Location
Owner's Name zoLn
Map/Parcel# �j
Address G
Lot#
Telephone#57—
Installer's Name
Designer's Name ,/59-
Address�. �� ��� /
Address
Telephone#cf ro p fpJ 3 p
Telephone#
Type of Building �4-1101 L 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
1
DESCRIPTION OF REPAIRS OR ALTERATIONS //G�,0O0LlrQ� ��/�Gt/ t %�� _5�eO eAf TO
The undersigned agrees to install the above described. individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t to place the system in op a on until a Certificate ofCompliancehas been issued by the Board of Health.
Signed Date
Inspections
No.� 7—FEE C/ V
COMMONWEALTH OF MASSAC USETTS
Board of Health, � , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Wridividual Component(s) ❑ Complete System
The u dersi ne/d hereby certify that t e Sewage Disposal System; Constructed ( ), Repaired (1// Upgraded ( ), Abandoned ( )
by:G� vl G
at d 1?S-
has been installed in jaccordance with the prOVIsions of/910 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated w Approved Design Flow (gpd)
Installer//;A/l/
Designer:v"'i Inspector: / ice' 6,, ZZICIAI Date:
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.
No.
COMMONWEALT14 Of MASSA HUSETTS
Board of Health, /G�lif� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
M
FEE
�%J/ V //a �!V
99 (v�
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at e,' //'' ` as described in the application for
Disposal System Construction Permit No. Q�/ ���7, dated
Provided: Construction shall be completed within -15F of he date of this/Tfe knit All local con itions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �"' Board of Health sCl/
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