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Board of Health, MA.
AP PLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
LocationEs,
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Owne?s Name
Map/Parcel#�oa��
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Address
Lot#k
Telephone#
Installer's Name
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Designer's Name
Address
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Address
Telephone#
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Telephone#
Type .of Building Lot Size sq. fr.
Dwelling -No. of Bedrooms Garbage 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
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The: undersign .a ee to install the above scribed Indi' ual Sewage:Disposal System in accordance with the provisions -of TITLE 5 and
further agrees to lase the sys peradon un i a Certificate of Compliance has been issued by the Board of Health.
Signed -Date
InspectionsJI/ _ l)kJI
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C®M1`�1/,r O WEALTU OF MASSACitIUSETTS
Board o f Health;&d? jMj i , MA.
CERTIFICATE /F COH.A1�T err` FC
Description.of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal ystem; Constructed Rep,red Upgraded ( ), Abandoned ( ).
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has been installed in accordan e with the prov' ions f 310 MR 15.00 (Title 5) and the approved design plans/as built plans relating to.
application, No. = dated -` e :`'Approved Design Flow (gpd)
Installer M 1 ;
Designer: Inspector:.` �.- Date.:
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n; f be.construed as a guarantee that the.system will -function as designed.
The issuance of this pe`z rritpts�ia
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1f MASSACHUSETTS
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OSAIa S STEM CONSTRUCTION PERMIT o..v jtxe
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Permission is hereby granted to; Construct(Repair Ylpgradan individual sewage disposal system
- .f .d .`•
at . MS 10,4Z as described in the application for
Disposal System Construction Pextrt Nc r " latecl
Provided: Constructiomshali be completed within three years of the date of this permit. All _local conditions must be met.
Fnrm 1255 Rev. 5/96 A.M.:Sull in Co. Chatles(oWn, 6v�: Date •/1 Board of Health
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