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FEE
COMMONWEALTH OF MASSAC14USETTS b,4(
ARMOUTH HEALTH DE!
r�
Board of HealtT
#6 ROUTE 28
APPLICATION FOP, DISPMX�RV?M?4MRMRUCTION PERMIT
Application for a Permit to Construct( ) Repair (A-.*U'pgrade ( ) Abandon( ) - ❑ Complete System 04rdividual Components
Location 2 N- M Al,v 5 7- S o t//J/r
Owner's Name W4 ,L, t' /e % C41+7je
Map/Parcel#
Address d719 Al— T A to< -
Lot#
Telephone# g4�
Installer's Name ,� �+ (j
Designer's Name
Address 3Sp �� sr- w.Y�ie
Address
Telephone#
Telephone#j,
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
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
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS rt- �L /g C F �/ F /�ays %p JyJI�/ � /DovL-
.k/tiiti 10-0 Z- -;'r0_r Dyffc rL®w
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr es to not to place the system 'in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed , r Date f %—®s
Inspections
COMMONWEALT14®F MASSAC14USETTS
Board of Health, �/_7 � , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Lrl5Qvidual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( *�<pgraded ( ), Abandoned ( )
by: _ e a ly r o ?.£ O on p 1A.- S r wA R
at 4/:2 Al a e7// m k A,, T T S G �i7iP
has been installed in._ccorda ce with th�rovqLsons of 31,(1 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. t% 7 dater% �. Approved Design Flow (gpd)
Installer r� -
Designer: Inspector: Y2 f Date:
The issuance of this permit shall not be construed as a guaraee tha the system will function as designed.---- — —"
No. v / �K t( t t J FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health,l- 7/,t , MA.
DISPOSAL SYSTEM ONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade ( ) Abandon ( ) an individual sewage disposal system
at `/� N -IV4/N ST 5 -
Disposal System Construction Permit No..�"_, dated -f 7, .�
as described in the application for
Provided: Construction shall be completed within three years of the date of this ernit.local conditiops"Imist be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health C J