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Board of Health, ii 8
V APPLICATION FOR DISPOSAMMTbASIMMION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade. /Abandon() - 0 Complete Syste7-dll�dividual Components
Location �' sy �S�C,�G/ !/n
Owner's Name
Map/Parcel#
Address %hA,
Lot# 11
Telephone#
Installer's Nam e`i��� 0- f
Designer's Name
,Address -3 &-1?4�lf
Address
Telephone#
Telephone --Z
Type of Building ::� 20"z o L✓ Lot Size � 9d 7_ sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of person Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)�l� gpd Calculated design flow ,1$ Design flow provided gpd
Plan: DateNumber of sheets ! Revision Date y IiYL,P
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 5 F
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The undersigned es to ins 1 the a ov scribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr es n t to a ertificate of Compliance has been issued by the Board of Health.
Signed Date
-r
No. % t-471'-
/QFEEC®I� MONWEALTH Of MASSA_ TTS k- Z -/ 0 �, o
Board of Health, J - z� -
CERTIFICATE OF COMPLIANCE
Description of Work:,d�ndividual Component(s) 0 Complete System
!The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,(— Abandoned ( )
by: J�
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. lei - 9 % , dated Approved Design Flow (gpd)
Installer y
Designer: SS2j(/6 k"Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, �%U'l ef' , / 1l , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( )
at
FEE
6
Upgrade( ) Abandon( ) an individual sewage disposal system
✓� L> � -,� as described in the application for
Disposal System Construction Permit No. 7, dated
i
Provided: Construction shall be completed within t�e-4 of the date of this permit. \All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown,MA Date 'G1 Board of Health