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COMMONWEALTH LTH Of MASSACHUSETTS
Board of Health, % MA.
FEE o
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AP PLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) 'Repair(,<Upgrade( ) Abandon( ) - ❑ Complete System A-1<ndividual Components:
LocationOwner's
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O
Name 10 '.iia
Map/Parcel#
Address L� *'o'/ Ts/ . �'
Lot#
Telephone# 5dL? :3!c,7
Installer's Name E S/j
Designer's Name ._..'
.Address 3 0�� /lam!
Address
Telephone# !j'
Telephone#
Type of Building I if 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) gpd Calculated design flow Design flow provided gpd
Plaits 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
The: undersigned.a s to _stall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and;
further agrees t t 1 the m ' e a Certificate of Compli ce has een issued by the Board of Health.
Signed Date
t
Inspections.
No.A'L� c� - (�- 39 COMMONWEALTH ILTH OF MASSACHUSETTS FEE N
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Board o f Health, jmo d a , MA.
CR.TIFICATE Of COMPLIANCE
Description of Work: dividuai:Component(s) ❑ Complete System`
e 7(
The undersigned hereby certify that the Sewage Disposal System; Constructed( ),Rep aired , Upgraded ,band
Aoned (.
by 015` ACL) 14,s Co "
at z e �Qi i tis°
has been installed in accoa ance with the provisions of 310 CMR"15.00 (Title 5) and the:approved; design plans/as-built plans relating to
application No. dated, '' Approved Design Flow (gpd).
Installer -
Designer; Inspector. Date::
The issuance of this permit _shall not be construed as a guarantee that the system will function as designed.
No. _ / (✓(,l S " . i FEE' _A
9 � �
COMMONWEALTH ONWEALTH ®f MASSACHUSETTS 3-7yt
Board of Health, VAft 0) MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abanfdon ( ) an individual sewage disposal. system
. 007
/ C l described in the application for
Disposal Syste Construction Permit No. , dated `
Provided: Construction shall be completed within three years of the date :of this p m` ,.+All local conditio . must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Chadestown, MA Date Board of Health L