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COMMONWEALTH OF MASSACHUSETTS
BoardofHealth,TPrgMQ(rA14,' ,MA•
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair( ) Upg�jldlti2 ) Abandon( ) - ❑ Complete System
I�GG 7 � 2019
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Location (
Owner's Name
Ca vi�6
Map/Parcel#
Address cJ
Jar x 1,
Lot# J
Telephone#
Installer's Name t/'
Designer's Name
Qui' tE .ir L��nL
Address
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Address �'�
C /W
Telephone# _hlu4ub
Telephone#
Type of Building ay�-),IckybaA Lot Size Ids/ (W sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building �,No. of persons Showers ( ), Cafeteria ( )
Other Fixtures r�
Design Flow (min. required) 33Co gpd Calculated deli n flow Design flow provided -,3S( gpd
Plan: Date I 1 0 sQ( 6d_ Number of sheets _�_ Revision Date MZZ4
Title
Description of Soil(s)- SPe �d? C 3a atm JI tf t /%T e� iivv Ser, v�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS .d n 7`
S ,r P W— ,n C Ile wi �cr� i iG�✓' 1� lC' 1 84 1 o �C
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 CoTpliarre has been issued by the Board of Health.
Signed .d ✓%!'" Date (IJ�.
No 1 ti01;� `� i �) ...-� r�� dF + FEE "� d�(."
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COMMONWFALT14 OF MASSACHUSETTS � �' f �I Z,���
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Board of Health, ,4i7s n" 14-- MA
CERTIFICATE OF COMPLIANCE
Description of Work: ,Drindividuat Component(s) CIComplete System It"` t-`-' "�'
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,.(—), Abandoned ( )
b l , IL 4 r:%' _"t Jl �r d ? u eke' - ' )( Z7 1, )LI, '�
Y�
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated . Approved Design Flow '70 (gpd)
Installer 1
Designer. `-Yd n +`" 1_ Inspector` rt ,_0 ` s4=-�l'�,.. Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No FEE',
COMMONWEALTH OF MASSACHUSETTS '` °"
Board of Health, A"Lryie)t1111 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade. -) Abandon ( ) an individual sewage disposal system
at ; l�� l` [ P ", `4 f ,h u i t/1 'r l i �.rt� � as described in the application For
q.
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this pertntt All local conditions must be met.
Form tzss Rev.5/96 A.M. snikm Co. DatslmmNA Date 6 4 � < i- r Board of Health--