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C_�5u" Board of Health, i? MA.
APPLICATION I -OR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System D Individual Components
LocationOwner's
Nm .a ,31 A-Vj
Map/Parcel#
Address d�-
Lot#
Telephone#
Installer's NameAA
kADesigner's Name %
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Address
r' Address
Telephone#
_ e" ^ r. C� Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
Design Flow
Plan: Date =
Title /"-)l
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS
gpd Calculated design Bow
Name of Soil
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to noace the syste hi operation until a Certificate of om"Hance has been issued by die Board of Health.
Signed A® � o ' /�� Date
hisprctions 2// / �� 6 " —
No ,f) ..� (w.� cP ..(�tlr� � , FE
COMMONWEALTH OF MASSACHUSETTS c ,� 1 r 473
Board of Health,^' oo- l 7 , MA, ti y„ a a
CrRTIFICATI E OF COMPUA TCS
Description of Work: ❑ Individual Component(s) ❑ Complete System''
The it
gtdet signed hereby certify tify that the. Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (V) Abandoned
by S I 01 '( tg r i t, i 1"i, C� r) �I)V/ ti .-.t,..f11
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at
has been installed in accordance with the, propyisio�yn of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application :y "" lc4t dated `"`'d'<�er*d�1te Approved Design Flow 'i .n,G`) d
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Installer + LA �' r, `rql 'j"1i �1., t j% `�, { (1�..Yi` t "M�i
Designer '°�'-x"-` t`< _I`,r ` V "� Inspector: . d'�N�''""" Date: s"Y^
The issuance of this permit shall not be construed -as a guarantee that the system will function as designed.
k.Fmk COMMONWEALTH OF MASSACIIUSFTTS oAA�
Board of Health, �Y A- w)16 M MA. .
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
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Disposal System Construction Permit No. d s° dated i' a It 'd � .
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. SUINin Co. CladeslavM1 6U1 Date Board of Health e