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COMMONWEALTH LTH Of �' ASSACHUSETTS d°0 q
Board ;if Health, Y"MU" MA. ItAw 14 Dor / /j�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradqL,�—AbandonO - ❑ Complete System .�Mdividual Components
Location: �j
Owner's Name
Map/Parcel#
Address
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Lot#T
pele hone#
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Installer's Name a �C ^ fu
Designer's Name
AddressAddress
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, tU' V% mc� P64 9, ol�
Telephone# SQ 77 6- G y C,
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Telephone*
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Type. of Building Gi[/tJ'A 1 _ Lot SizelS COO sq. ft.
Dwelling -No. of BedroomsGarbage grinder
Other - Type of Building No. of persons Showers (' ), Cafeteria (
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets _ Revision Date
Title
Description of Soil.(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS c.IA CACJr- c j A k I Y60941A 1
The undersigned, agrees to install the above described Individual Sewage.Disposal System in accordance with the provisions of TITLE 5 and;
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
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Signed., �� G.�-ter Date
No Ib�--C�o1�-{ f�EF
- � COMMONWEALTH Of MASSACHUSETTS6��'� � X00
Board of Health, , MA. p`DV
CERTIFICATE Of COMPLLANCE /�lr"�1
Description
Work:'Individuai Components) ❑ Complete System
The undersigned hereby'certif . that the Sewage Disposal System; Constructed ( ),.Repaired ( ), Upgraded.__);tibandoned ( ).
by.
at (SS i"� v» e !c 44
has been installed in accord nce with the rovisions o 310 CMR 15.00 (Title 5) and the approved design plans/as built plans relating to.
application No. da / . Approved Design Flow (gpd)
Installer 4.
Designer: DG' PG Inspectors� irk
The issuance of tbis permit shall not be construed as a guaY'antee that the syst(
FEE ; (Sr, 0
COMMONWEALTH Of MASSACHUSETTS to
Board of Health, ���V , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(- -'-Abandon (` ) an individual sewage disposal system
at (0C7G t°► e )G+ G4'� as described in the application for
Disposal System Construction Permit No. -/ dated' 1 .
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. Chadestown,MA Date Board of Health r /�