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f Q'� COMMONWEALTH Of MASSAC14USETTS
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o��d of�>'ealth,MA.PLICATI®N F DISPOSAL' SYSTEM CONSTRUCTION PERMIT AW44--b-0 co,,A
Application for a Permit to Constructj/�pair( ,) Upgrade( ) Abandon( - te'Complete System ❑ Individual Components.
Location 55 D Y 1il➢ tL
Owner's Name Ct 1 vi
G 1 n , r
Map/Parcel# ,
Address
Lot#
Telephone# 5 ( x , a 'I.
5515 2�
Installer's Name f t
Designer's Namei
- t
Address S30
Address 6 C
F al
Telephone#
Telephone# � 3(,7-'-
5-4
Type of Building n Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building, No. of persons Showers( Caf%eria ( ).
_ 6
Other Fixtures
Design Flow (min. required) gpd Calculated design flow _
Plan: Date Number of sheets
Title
Description of Soil (s)
Soil Evaluator Form No. Name of.Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow providedgpd
Revision Date
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of T= 5 and
further afire, to not to ce the system ' operation until,a Certificate of o ice has been issued by the Board of Health.
Signed Date
InspectionsZ r — f
No.
FE)
COMMONWEALTH OF MASSAC14USETTS eA
t Board of Health, , MA. _ J
('11TIE I TE f)IE ff)M PI TANFE
Description of Work:
The ndersigned her
bv: .h fil-il /AAA A
at r� k
has been installed
application No. R
Installer 0 t1 rjr t
ul Al
O Individual Component(s) complete System
eby certify that the Sewage Disposal System; Constructed ( ), Repaired ( )UpgradeAbandoned ( )'
accordance with the provisions of 310 CMR 15.00 (Title 5) and t e pproved, design plans/as-built plans relating to
dated. Approved Design Flow (gpd)
s
Designer: a , �fe a10P Inspector:�'etha
l �.`.! Date;
The issuance of this permit shall of he constru d as a guar the system will function as designed.
- No. i E�C-'1 6yZ' O C r` }c1 C.fl 17 tS C/i�� FEE
COQ MON LTH Of MASSACHUSETTS
Board of Health, y PrOM0L , MA:. y
DISPOSAL SYSTEM[ C®NSTRUCTI®N PERNIIT
Permission is hereby granted to; Construct( ) Repair( ) UpgradelQD Abandon( ) an individual sewage disposal system
at t;_ __Y 3� iti;f'�t)i� �I{ 1 jj`r''' as described in the application for
Disposal System Construction Permit No. R'' , dated-'�
Provided: Construction shall be completed within ti Pakrs,off < date of this p rmit�All local conditions must be met.
Form 1255 Rev. 5/96 A.M.Sulkin o.Chade5lown,MA Datd–/11 7 Board of Health