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C®MM® W TE �VA'F USETTS
1146 Board of j /� �7 , MAT
APPLICATION FOP DISPOSAL SYSTEM STEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name IlAle Y;
Map/Parcel# ! b
Address
!S 22ef—
Lot#
Telephone#
Installer's Name T��,'
Designer's Name
Address /
Address
Telephone#
Telephone#
Type of Building 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) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Design flow provided 3 3U gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 6�o/9l' � 4& ,&gam
D ���
The undersigned agrees to ' tall the abov escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t c the systexpffn operation until a Certificate of ompliance has been issued by the Board of Health.
Signed DateI al
I 1 y U
Inspections
,/No.o7 ja-7
COMMONWEALTH`
` �/� �T��T�~ Of MASSAC14USETTS
FEE
Board of Health, Ct e" a MA
CERTIFICATE Of COMPLIANCE
Z1 1,-,
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereb certify that �he Sewage Disposal System; Constructed ( ), Repaired Graded Abandoned ( )
by: r
at
has been installed in accordance with the prov'sions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 7 , dated l / Y167 . Approved Design Flow _ (gpd)
Installer / /71 _.
Designer: Inspector: U 7 t Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 617 -3 a % FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, VlaAA MA.
✓+ `A ti y 9�
DISPOSAL SYST&I CONSTRUCTION PERMIT L l 4n 2 C., A
Permission is hereby granted to; Construct ( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
2
at a h ��- /�P. 31'lae as described in the application for
Disposal System Construction Permit No.0 3 a7 dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date i G Board of Health /2�1