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COMMONWEALTH Of MASSACHUSETTS CA"2A
A
(I Board of Health, 'YCW&QI-0 �-k , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application for Permit to Construct( ) Repair( ) Upgrade{. Abandon( ) -o' Complete System ❑ Individual Components
Location (o57 "C�.-Z-j %VVW
Owner's Name ��re A t1(`C ✓�
Map/Parcel# 79 -24 0
Address -70-7 m Ar Ci V% V1 (S IM%A 67-fcU )
Lot# 51
Telephone#
Installer's Name �13��slRy
(Yt;.1 Designer's Name ,rty:��zr� %rtu �i,C_
Address s H, /�- L� �a t1
^i
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Address 1 Z W • S3
Telephone#
Telephone# SQ Y- (f -,r7--5-31D
S
Type of Building S, GL �i � 4 S (lis, tm7"� Lot Size G e-(- .Sq. ft..
Dwelling - No. of Bedrooms Garbage grinder {
Other - Type of Building, :^.l No. of persons Showers( ),Cafeteria( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow '375CJ Design flow provided gpd
Plan: Date 9 Number of sheets Revision Date
54 1Title wc��l lcxf i-1-,
Description ofSoil (s) L.S �'Z LS Zy-7 �/."C$-1Zc� �Z MS i'12f�—tZ�
Soil Evaluator Form No. Name of,Soil Evaluator Pt=e•-�OC:t � Date of Evaluation 4- / `4- 1
_
DESCRIPTION OF REPAIRS OR ALTERATIONS
�/ EX �S Y C•e it �acrr� �h S �'C i� l S. �� Y _l -S
d Z -yo U
The undersigned agrees to install the above describe& Individual Sewage Disposal System in accordance with the provisions of TITLE 5' and
further agrees to not lace sb n o er 'o until a Certificate of Compliance has been issued by the Board of `Health.
Signed Date $-rl51 Q
Inspections
No.,!�✓t.l �-� .S'� f �.� FEE
COMMONWEALT14 OF MASSACHUSETTS 2-1
Board of Health, )� +rm c= --s �-I_ , MA. pV
CERTIFICATE Of COMPLIANCE
Description of Work:. ❑ Individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Dispo. I System; Constructed ( ), Repaired (}, IJp raded,( ),Abandoned ( )'
by:. C s:' c. - e a GR ea rzae �w„t� C G. • a
at 1 � -- P Mao '
has been installed in accordance with the provisio s of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.dated T" l . Approved Design Flow V5 (gpd)
Installer % ,° L 6 ..r / ,y -
Designer: "•, �[°� (`-19`+rCi{3 Inspector: :r1 Date: 7
The issuance of this permit shall not be construed as a gua tee that the system will function as designed.
No. {1 r�-� 1() FEE x
COMMONWEALTH Of MASSACHUSETTS C482i
Board of Health, yca ✓.tea<l a -}-1, , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;, Construct( ) Repair(. ) Upgrader(+(' ) Abandon ( ) an individual sewage disposal system
at 45-- �ci Z t tt ray) s� f ' -,&'. yf P`✓1+6 .
i a as described in. the application for
Disposal System Construction Permit No. �� c ` , 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. Chafestown, MA DateW-1-,C—/Board of Health