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COMMONWEALTH OF MASSACHUSETTS
Board of
rfHealthOLK rYlU3r r MA.®C rJ)-V'
°'�eoS "?APPLICATION FO -11 DISPOSAL SYSH
CONS TI RUCTION
SEP 0 5 2019
TH DEPT.
Application for a Permit to Construct( ) Repair("I) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 10 t�- - • �- �hl:.
Owner's Name 1w)4 -RA °=
Map/Parcellf
77
Address((,,,, -+P`V,
Lot#
Telephone# SG ( j
Installer's Name Ul4'L1`C u(- co
Designer's Name Reye' e qr', 5' v , ; qr- n7 ..
Address "• G' %tl�F. t !�'
Address �050 -'{
Telephone# C as,_ o . c�+�
Telephone# C' •- 7oq
Type of Building
Dwelling -No. of Bedrooms
Otter -Type of Building _
LotSize lar i&lfi sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other FixtmMs
Design Flow (min. required) gpd Calculated design flow Design flow provided / ��/'� gpd
Plan: Date Ems+ 1 !7 Number of sheets -3 Revision Date - /'T TJ„i
Title
Description of Soil (s)
Soil Evaluator Form No.
Name of
�- Date of Evtduation
J
DESCRIPTION OF REPAIRS ORAITERATIONS I tWSr v )1 l s b(r Q c, iL . Ti% 0 `4 •-�3('y ,(� , ,Q� �,,4 y
• The undersigned agrees t n tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t e the S)! ApgiIt operation until a Certificate of Compliance has been issued by die Board of Health.
Signed / Date
No;&4•{ci4_55
., ",.a tq W rel'
. � COMMONWEAILTbI OU 1MASSACIITISEITSI" � til®; �t
r � • ` r e`" p° dwa �-
Board o/Herdlh, Yfi(UA f>t) a� g MA.
CERTIFICATE OF COMPLIANCE 08119
Description of Work: O Individtud Component(s) ❑ Complete System e" `
The undersigned hereby certify, that the Sewage pisposal System;. Constructed ( ), Repaired (1), Upgraded; (+` 2Abandoned ( )
has been installed in accordance with therrorisionst„ f 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. "'+°- ,date _- Approved Design Flow ^`".^'�'`.�^� (gpd)
jS n
Installer _ I"'*,, 6 " 4 d t" 6", . r
Designer:),ll�:a.',n lc, g,�y., t r. S•••zC? 1 t 11 b°''` 9 t.'L( Inspector: 4,44,10'X,) g ^a�Y.,2`^'?�'tc'"`"4..�,f Date:
s..,
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No :i
,VDD(..1 C) .,. ""` C y...v<,b t„} ..,
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y aQ °c% l-)' a , MA.
FPC
DISPOSAL SYStTFM CONSTRUCTION PERMIT
Permission is hereby gran Led to; Construct( ) Repair(, -"/
Upgraded_ Abandon( ) an individual sewage disposal System
at 1 6 1 d 1; 1' " `•" as described in the application for
c'
Disposal System Construction Permit No. S `'� " a= , dated ) li 2
Provided: Construction shall be completed within three years of the date ofthis tail local conditions must be met.
,.
�
Form 1255 Rev. A.M.AM SulkinCo.Cled4w,KA Date �( ) Board of Health
4 \<%i [ 5 l" y -r. ..C„,o ,,,, ,/� t. f "� r� ) ,l. � , / �.. n: t �7 , 'P � G' ✓ a`tt 1 ; ''� f �,, � r �.� cl.