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Z0-02-7 COMMONWEALTH OF MASSACHUSETTS
Board of Health, �/d LM�l)Tk% MA.OEC09I-
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION P RMT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System ❑ Individual Components
Location \%(" (-•
Owner's Name -i-OD a t..�p4a�,-J-tkl
Map/Parcel#
Address L .A\j(a:pt2-i Lk&., e
Lot#
Telephone#
Installer's Name (�p ._. 1 e �.,,
Designer's Name - c Cto u-,eeD- & m -C c-,
Address _ S.p �
Address.2� 0p.. w, i ,
Telephone# "• • I--,,, -.2-f —'&;-(-7
Telephone# '-j)Z ,1R: -e j
Type of Building%��1�1 f-f�c:`l�l + t a'f-C.-- Lot Size 17),(94- 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 ( D� --� -A0 l C) Number of sheets Ir Revision Date
Title I AytaZ�j cWEtdlflt.3iR.d-
Description of Soil(s) _
Soil Evaluator Form No
Name of Soil Evaluator
Date of Evaluation 1 ( -a i -)-o t9
DESCRIPTION OF REPAIRS OR ALTERATIONS C,) 5 FZ G-kl.STe tJ 6` (( 000 C�-i.-i.-C�tL..) 51: ( f_- � '� K
7)) 06 0) d?e)y TO Gal 0�LA[) L iCv'C C6{�&r� fi ""�2S Gut i
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/�o,�place th system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �l _ Date. "'�.' c�£? (•� .J
Inspections
No �,`)r�i)('� P FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, J i i d18YT C fl- MA.
CERTIFICATE OF COMPLIANCE��
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ,(."•)' Abandoned( )
by . �,_ G # 1 A+r " " a Q, 4
has been installed in accordance with the provisio sof 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. "ti. t>- 02 "'1 , dated ! ':Z. "7 1i2t. Approved Design Flow (gpd)
o
Installer C�,# P 6< .C° d p P., M° P""" A e1 •`.d A- I , I
Designer: .., &3&fA.)4=:f^ F8 Am ., Inspector' :)'Yr( %r `8 R l' _ '`te, Date:
s.,,.`
The issuance of this permit shall not be construed as a guarantee that the/system will function as designed.
t J
No. `a' o .. c,,, °9� ° �i.. �..t ;t %ili c. t,.} =, r (:;.;ix . [);.)i:..
e
COMMONWEALTH OF MASSACHUSETTS
Board of Health, VL1? Le{5a.)ML MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
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Permission is hereby granted to; Construct( ) Repair( ) Upgrade (b)A ^Abandon ( ) an individual sewage disposal system
at ~ YCQC -1"tee , Y""le^ as described in the application for
Disposal System Construction Permit No. J t9 dated T i ) l t `:(
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be
Form 1255 aev.ss5 aM.smkmCo. cutesam,hn Date Y ��t 1 ;t t)'t l� Board of Health-'--