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Board of Health, _YAkNO011+ , MA.
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(} ❑ Completes System Q
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Location /
Owner's Name
;Map/Parcel#0
Address
Lot#
Telephone#
Installer's Name ,�
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Designer's Name ci
Address Dpi i
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Address
Telephone#
Telephone# to _. ,
Type of Building' + z .c 9 Q1 Lot Size sq. ft.
Dwelling No. of Bedrooms - Garbage grinder
Other -Type of Building No. of persons Showers (' ), Cafeteria
Other Fixtures
Design Flow (min,, required) J? O gpd Calculated design flow J? �� Design flow provided gpd
Plan:Date //`� ��� Number of sheets _ Revision Date
Title / (i/i TQC
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
LV Vt-N, 2-�aZP S,46 Z;'44,4
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The undersigned agrees to install the ahAwe described Individual Sewage;Disposal System in, accordance with the provisions. of TIME 5 and,
further agrees to no to place operation until a Certificate of Co �ili a has been issued by the Board of Health.
Signed the in Date l-1 11
Inspections
No.
6ovvDc �5- 3 a CO'l MON�L.T14 Of MASSAC�L� TS ('ep
Board of Health, ! �Q , MA. //14
_ CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify. that the Sewage Disposal System;: Constructed ( );:Repaired ((), Upgraded ( ), Abandoned ( ).
by:
at r ..'.'�°�Ala.
has been instaile cco#}• nce with the r �isioi s f 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to.
applcationNo„„.ee�� 1 ,dated �' / Approved Design Flower (gpd) t
Installer 14 11 C A-lT Q - -- /n /
Designer: I
The issuance of th
No.
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I not be construed as a guarantee that
CO MONWEAI.T14 OF
Board of HeeaTlth,
DISPOSAL. SYSTEM
Permission is hereby granted to; Construct( ) Re air( ) Upgrade( ) Abandon( ) an individual sewage disposal system
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ate I�/1��✓ � as described in the application for
Disposal System Construction Permit No: _11. , dated <_ -- '"T
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown,.MA Dated J-3 �� Board of Health t VV4,_