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No. Py� �k8 B oD tL— � Y "00 q / G 7 FEE OV
%!— C®11_(ONWEALTH OF MASSACHUSETTS V C � 0
aarddfFlealt/z, Yt1�'/YIZScIi�� MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Rcpair( ) Upgrade( ' AbandonO - da/mplete System ❑ Individual Components
Location
4C
Owner's Name
Map/Parcel#
Address
Loth 65Telephone#
6-7 .308 -
! ^Installer's
Installer'sName
; Ke-- L 41 d 6&H
Designer's Name
A "^
Address O
70t
Address
cI G,
Telephone# Sc
.7-7G
Telephone#
-NSy
Type of Building I `�7 lSrdt, JZ.el Lot Size 1 � ft.
Dwelling - No. of Bedrooms i!((G Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. rec aired) 330 gpd Calculated deli n flow 33v Design flow provided 3y� gpd
Flan: Date Number of sheets 1 Revision Date
Title
t
Description of Soil(s) t/' to
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORAITERATIONS
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 to place the system in operation until a Certificate of C mp cc has been issued by the Board of Health.
Signed c i -� Date G t 501
..r %tom t" d well
I'' I "�t �:"�•ir`P C%?3e "✓ g✓""l 1
No. -i f- ,"� "(°^` G. 1 x FEt °.`
COMMONWEALTH OE MASSACH SE, r' ., o`� Q
Board of Health, Yz ?d`M tr)-;4 MA. 011 0 (2P
CERTIFICATE OF COMPLIANCE
Description of Work: D Individual Component(s)-O,,Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (c,+; Abandoned ( )
by: K 'Ff "� / V € r ' 4
has been installed ig,accozda ce with the Provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.€ dated .;9 _ r'!'• .Approved Design Flow -'. /� (gpd)
Installer 'd -
v r •a
e a✓ �d a r r.l,.,r` (.� .;±';�.' Date:
Designer: ��� .. f� z✓� t��w,.,,m _a... Inspector: _ F
The issuance of this permit shall not be construed as a guarantee that the system will function as desiymed...
No. FEE d�s..e%.. )
n'
COMMONWEALTH OF MASSACHUSETTS
Board of Health, P)t:>ML( , MA.
DISPOSAL SYSTEM CONSTRUCTION PMJ IIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( )^ Abandon( )an individual sewage disposal system
at /I Ce' -J/-"" 0'r) E') as described in the application for
Disposal System Construction Permit No. l_,/daatted %°` %
Provided: Construction shall be completed within,tbree v6ar�jof the date of this permit. All local con, tGons must be met.
Porn 7255 Rev. 5/96 AM, $uikln Co. Clade9oNn, 61A Date''i F, /"/ Board Of Health
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