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.-COMMONWEALTH: OF MASSACHUSETTS ck*41131
bard ofHealth, MA.
APPLICATION M DISPOSAL SYSTEM� �N SUCTION PERMIT
Application fora Permit to Construct Repair( Upgrade( ) Abandon( - Complete System D In
Components
Location litK(k)
004 a-k� Owner's Name VaLs bl+�
Map/Parcel# �'
1 I(a Address % J'e i(%".
Lot#
Telephone# oo 1 � �)
Installer's Name
Designer's Name BSG r
Address 30 K6LU4tcro
Address 3,vl DAIA2
'
Telephone#IM 6Telephone#
_ '1-1
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building, No. of persons Showers ( ), Cafeteria ( ).
Other Fixtures
Design Flow (min. required) --�� gpd Calculated design flow Design flow provided - gpd
Plan: Date Number of sheets Revision Date
Title
Description of S°oil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS o
The undersigned agrees to ' all the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to p1 c he tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed DateIt
No.UHV-t8`3`12(o s � FEE
COMMONWEALTH LTH OF MASSACHUSdT,v
Board of Health, &9Wti, MA.
CERTIFICATE OF COMPLIANCE
Description of Work:. 0 Individual Component(s) plete System
The undersigned hereby certify that the Sewage Disposal System; Constructed epaired ( ), Upgradedj, �kSandoned ( )
by:2
at I`�C3 `TJi � # u xlra L"i
has been installed in accordance with the provi 'ons of,40 CMR 15.00 (Title 5) and the approved design plans/as,-built plans relating to
application No. _, datedo-% 4e 446. Approved Design Flow or 7 (gpd)
Installer (I-h(VV 4 RI P y C. 't4,{ _ _ - '_.
Designer: �.. Inspector:�teeat
Date: The issuance of this permits all not be ,construed as a guar the system will function as designed.
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, 0 M4 , MA.
DISPOSAL. SYSTEM[ CONSTRUCTIONPERMIT
Permission is hereby granted to;, Construct Repair( ) , Upgrade x , """ Abandon ( ) an individual sewage disposal system
at 0 q ! f+ I A ky,; i Lit V%,C_ as described in. the application for
Disposal System Construction Permit No. , dated '=fd
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 . Sulkin Co. Chadegown MA� Datetd tr board of Health