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COMMONWEALTH OF MASSACHUSETTS
Board of Health, Ycrrftocl" A,% , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application fora Permit to Construct( ):Repair( ) Upgrade(() Abandon( ) - W,Complete System ❑
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JUIN 2 18 ?r1"4
HEAD Til H+ DEPS-.
Location VT to we,- 9,/c&C(
Owner's Name (jr /� !7-e�Rpw u (`� .
Map/Parcel# S o .- r a7
Addresses rCi1 rLt C.r /" qs-4 � /�I4 6?(p 4
Lot#
Telephone#
Installer's Name "6-8
Designer's Name <
Address 3y ee�d-, tUI }- �V(�- 557tAddress
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Telephone# 316
Telephone# 3-60-g-77- 53 L
Type of Building i��si"lc J ``�'� � 1 �7 Lot Size / G, a� �� sq. ft.
Dwelling - No. of Bedrooms `� �� // tvo Garbage grinder { 4�
Other - Type of Building w A No. of persons Showers O,'Cafeteria
Other Fixtures A iA �;; ;Z
Design Flow (min. required) 8 gpd Calculated design flow ';Z4) Design flow provided:?_ _gpd
Plan: Date �p� zt 'll q Number of sheets I t t ` Revision Date
Title P��,:O j se,o�i2�,,��►NI 1`QQi'¢dtk AQvI . %`f
Description ofSoil (s) 6.'ALS 6 ZZ p: t-.9 - 2.e -_$v 4 .5;).L (d -a All S 129
Soil Evaluator Form No. Name of Soil
OR ALTERATIONS A44 e-*
Date of Evaluation /tel 9_
The undersigned agrees to install the above desc ' vidual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to placentil a Certificate of Compliance has been issued by the Board of Health.
Sighed Date
Inspections 6 CO- 0 ft'ops
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No. F)()Pi "-0,5 i FEE 4,Z- Co
COMMONWEALTH Of MASSACHUSETTS T
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GASP jeC—O i
Board of Health, �I1 J F" 0/0
CERTIFICATE OF COMPLIANCE o
Description of Work:. ; 0 Individual Component(s) Complete System _
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgradedl(, A`ba>hdoned ( )'
by: Gam: , 16&CO A -x Ci�rj...10lQ .d, #
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has been installed in accordance with the pr vi ns of 310 CMR 15.00 (Title 5) and
/the
.�approved design plans/as-built plans relating to
application No.j�' � QCO dated ' L Approved Design Flower !. (gpd)
Installer / / TTT
Designer: ems' Inspector:. Date:
The issuance of this permit; shall not be construed as a guarantee that the:system will function as designed.
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No. _�Cf 5 7 -DI boupb FEE
COMMONWEALTH Of MASSACHUSETTS 6k54WPJ
Board of Health, `; u Ems. t"�` °' MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT C
DeeS YrC I C
Permission is hereby granted to;_Construct(. )" Repair( ) Upgrade) Abandon( ) an indhidual;sewage disposal system
at 1>C� ! QG�-'"`''� �i c f l as described in the application fqr
Disposal System Construction Permit No. w v r- , 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.,SulkinCo: Chadestown,MA Date ! i Board of Health G-
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