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Board (f Health, Y%�l1ol��' , MA.
APPLICATION POTS DISPOSAL SYSTEM CONSTRUCTIONPERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - O Complete System O Individual Components
Type of Building(—'bl\11:e) W\.1 1\J 1V'(Vk Lot Size sq. ft.
Dwelling - No. of Bedrooms 1 /— Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Osler FiXtllreS
Design Flow (min. requit •ci) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets_ Revision Date
Title ___ /// "—
Descripuon of Soil (s) - I
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not h e r operation until a Certificate of Vompfiance has been issued by the Board of Health.
Signedl ' Datee
Inspections el / I G 1 C% CV C-
No. Cl ,..i.J ` &r, FEE r•^y :y,. .w
COT'[i MONWEALTH OF MASSACHUSETTS dZ - ((�l"i e
Board of Health, Ya -411,A401 71""� MA. c f 6
CERTIFICATE OF COMPLIANCEf- � •
C -i
Description of Work: ❑ Individual Component(s) O1 -complete System ' d ,,✓'
The undersigned /hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,dj; Abandoned ( )
I •
has been installed in accordance with the pr vislouti of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ,� �. / I `"l" `t , dated <` a (tau (e ^. Ap�p)roved Design Flow. (gpd)
Installer ..�`y'..ti..«. `7�� t ��"�i"��/ `d'��_� t>'° ,� Fes,,' < 1 ��I o -l- "' s:. �� ('�., •� �y )Gi 1Jfc..�a.S..�.
Designer:�-`fi-t-y^'I4''!''•Si i�' -_ htspector: Date:
Pw k
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No i;;�l;-�-fir' ��••)(!t�`7��---�' .Cx
COMMONWEALTH OF MASSACHUSETTS
Board of Hecalt)t,I -8-d�f 1 1 "d �- MA.
F
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Periniissionppislierebygrantedto;Construct( ) Repair( ) Upgrade((,r)^/,Abandon( )anindividualsewage disposal system
at m°%°iq'°��" d i �1 � l � �1 �' � > `•9`'t. fM I as described in the application for
Disposal System Construction Permit No. � �" 0 � ,dated t..)
Provided: Construction shall be completed within three years of the date of this permit All local conditions must be met.
Form 1255 PBV. 5196 A.M. Sultrin Co. Chaikslaxn, 61A Date gBoard of Healxh d
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♦ i J� ' •�
NO 0
Type of Building(—'bl\11:e) W\.1 1\J 1V'(Vk Lot Size sq. ft.
Dwelling - No. of Bedrooms 1 /— Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Osler FiXtllreS
Design Flow (min. requit •ci) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets_ Revision Date
Title ___ /// "—
Descripuon of Soil (s) - I
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not h e r operation until a Certificate of Vompfiance has been issued by the Board of Health.
Signedl ' Datee
Inspections el / I G 1 C% CV C-
No. Cl ,..i.J ` &r, FEE r•^y :y,. .w
COT'[i MONWEALTH OF MASSACHUSETTS dZ - ((�l"i e
Board of Health, Ya -411,A401 71""� MA. c f 6
CERTIFICATE OF COMPLIANCEf- � •
C -i
Description of Work: ❑ Individual Component(s) O1 -complete System ' d ,,✓'
The undersigned /hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,dj; Abandoned ( )
I •
has been installed in accordance with the pr vislouti of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ,� �. / I `"l" `t , dated <` a (tau (e ^. Ap�p)roved Design Flow. (gpd)
Installer ..�`y'..ti..«. `7�� t ��"�i"��/ `d'��_� t>'° ,� Fes,,' < 1 ��I o -l- "' s:. �� ('�., •� �y )Gi 1Jfc..�a.S..�.
Designer:�-`fi-t-y^'I4''!''•Si i�' -_ htspector: Date:
Pw k
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
�t t
CIE "
No i;;�l;-�-fir' ��••)(!t�`7��---�' .Cx
COMMONWEALTH OF MASSACHUSETTS
Board of Hecalt)t,I -8-d�f 1 1 "d �- MA.
F
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Periniissionppislierebygrantedto;Construct( ) Repair( ) Upgrade((,r)^/,Abandon( )anindividualsewage disposal system
at m°%°iq'°��" d i �1 � l � �1 �' � > `•9`'t. fM I as described in the application for
Disposal System Construction Permit No. � �" 0 � ,dated t..)
Provided: Construction shall be completed within three years of the date of this permit All local conditions must be met.
Form 1255 PBV. 5196 A.M. Sultrin Co. Chaikslaxn, 61A Date gBoard of Healxh d
Rm