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COMMONWEiW /?
TS
Board of Health, 1146 ROUTE 28 Y
S�YAR
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - :'Complete System ❑ Individual Components
Location 6 C/
Owner's Name
Map/Parcel4k �� ,�,
Address S y' -x
Lot# �j
Telephoned!
Installer's Name l
Designer's Milne
Address / ,.� LGS
Act ess ''
Telephone#
Te, 'p tone9k
Type of Building I -<C,7-
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
Design Flow (min, require¢ /) i!J
Plan: Date !t-1��•z'J7'X N
Title
Description of Soils) _
Soil Evaluator Form No.
DESCRIPTION OF
r,1
No. of persons
Lot Size 911= sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
I Cah:ulated design flow _ Zro Design flow provided gpd
of sheets a _ Revision Date
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to mplIjpe alb ve s 'bed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees /t ooypto pl. e d system ' tion until a Certificate Vo has has been issued by the Board of Health.
Signed < '!�...r Date T, oG�
Inspections
sSYetdS
No. d19 -/OS- COMMONWEALTH OF MASSAC-TITJSETTS FE
Board of Health, �/7F{/YY¢>� MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) IfComplete System
The undersigned hereby certify that the Sewage Disposal System; COnSn'nCted ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
has been installed in accordance with the provisions o)yMO CMR 15.00 (Title 5) and
application No. dated F7 / ��' Approved Design Flow
Installer r.& 9/v tltlely /C�Lf -.R%7Y P?, i%[`.✓_ i
Designer: (ra`IJ/ L4.,V/2t-") Inspector:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH OF MASSACHUSETTS
Board ofHoalth,���'A Jacwl , MA.
DISPOSAL SYSTEM CONSTRUCTION HERMIT
FEL gip,.? -61 1
p
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Permission is hereby granted to; Construct(l,^ Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 6-6 as described in the application for
Disposal System Construction Permit No. /fir -i t ""��`�, dated
(;,/ u-4
Provided: Construction shall be completed within threewcaas of the date of this permit. All local conditions must be met.
t .
Form 1255 Rev. 5/96 A.M.Sorkin Co. Boston MA Date Board of Health ' t .✓' / �� ^"� `'�"�,"
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