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COMMONWTALT14 OF MASSACHUSETTS
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Board of Health.
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APPLICATION FOR DISP09AT9iR4TM,,`e(9NV- RUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System Irl Individual Components
Location
Owner's Name
Map/Parcel#
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Address �o C 4-o U u ,
Lot#
Telephone# ISZ)G -3-7 S - (o s -
Installer's Name
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Designer's Name
Address I
,v 061% s
Address
Telephone#
S
Telephone#
Type of Building Pz ��? i {�(J 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)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install thove described.Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
fur to not t m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
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Inspections
No!O3 �= /i� lis 46 FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, \t A' M Q V T , MA.
Description of Work:
The undersigned hel
by:
at
CERTIFICATE OF COMPLIANCE
4dividual Component(s) ❑ Complete System
certify that the Sew a} isposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
O r+11 ," G� —el
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has been installed ' ac ordance with the rPv. ons of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application N U_ 1 ted _�/ 9�G`� Approved Design Flow (gpd)
Installer >`
Designer: 11"VVI r r c•f L- C— Insp
The issuance of this permit shall not be construed as a
No.� `lJ�
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y"V, o Nq.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is ereby granted to; Construct()
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FEE
Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit NoOL-/' 13 dated �✓ G `�
Provided: Construction shall be completed within three years of the date of this mit. l loc nditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date/�/G� Board of Health