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APPLICATION FO -11 DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
i
Owner's Name--'t°Jt" Q, >, p r
Map/Parcel#
G•" `/7 '- SI
Address F• U C:
Lotlk " o
Telephone#
Installer's Name
R{"�`'
Designer's Name
Address POR,-,�(
0,-1Lj
Address
Telephone#
Telephone#
Type of Building Lot Size sq. ft.
Dwelling -No.of Bedrooms W arbagcgrinder( )
Other -Type of Building No, of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
_gpd Calculated design flow
Number of sheets
Design flow provided gpd
Revision Date
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
The undersigned agrees to insFtemo
above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to pl,/peration until a Certificate of Compliance has been issued by the Board of Health.
Signed /' i Date �. f f
Inspections ..
p�ii
���•66**,, gg
No Co((ddol ➢dc -9t.1 16'1- 1 FEE 4197 0)
COMMONWEALTH OR MASSACHUSETTS
Board afTreal(ll, YA R04 O 14 , MA. a �
Description of Work:
The undersigned her(
CERTIFICATE OF COMPLIANCE jhalb l ��1
Ellindividual Component(s) ❑ Complete System ,
certify that the Sewage Disposal System; Constructed ( ), Repaired (,,),,Upgraded O, Abandoned ( )
at 5 i Is" 9
has been installed in accordance with the
application No. I C1- -",& 1 , dated
310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
_. Approved Design Flow 11(gpd)
Installer b
„ .,.w4t Date:
Designer: Inspector:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. i
No.
Permission is
at
COMiMONWEALT11 Or MASSACHUSETTS
Board of Health,. P17 -M001-14- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
granted to; Construct( )
FEE 00)
�•'0 i
44 10100
Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
rn
Disposal System Construction Permit No. ) GI ",=, dated I
114, ,
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/95 A.M. Witt Co. ChVesmnNA Date Board of Health f ?✓�i✓ 1
1 ` ° ✓r ,