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No. 5 ,» ci fi J S'3 ',4/'l d"- \ FEE SS, 01
COMMONWEALTH OF MASSAC14USETTS � roe
\I/-►-�.UQQ- 4 , MA. DEC 02 2019
Board efFlerelUy
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIE }-i,
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - O Complete System Cl Individual Components
Location I C J .P._.(" Al C;
Owner's Namc 7)4'0 l Ci 7 D
Map/Parcel# q'cC
Address 'C (' ,, (F<
Lot#
Telephone#
Installer's Name ��� '
Designer's Name LA6C i�' ! P•t.? �' %�
Address o ®bid(�:Wii,1 /(.�C
- ,•�t„)., - Address
Tele hone#
Telc hone# pO
Type of Building Lot Sizea��� 'i� sq. ft.
Dwelling - No. of Bedrooms 43 Garbage grindettW
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other
Design Flow (m//in. /required) !'i C� gpd C51culated design flow
Plan: Date t C���.-%- `7 Number of sheets _ -11
Title
Description ofSoil(s) l
Soil Evaluator Form No.
Design flow provided
Revision Date
i
Name of Soil Evaluator ll L 2.C',hf'tx' Date of Evaluation
DESCRIPTION OF REPAIRSORAITERATIONS "F,
A) (-La' A f --S
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 two pl e sy/s�T%�,operation until a Certificate of C mpliance has been issued by the Board of health.
Signed � J /,rl" Date
Inspections
No. t�nki )C -l^"=1 ....�,"t.'>LY Iw) h�-)S"' e" :� FCL
t —
c? '7- r COMMONWEALTH OF MASSACHUSM t, fl" 4
Board of Health, MA. '/X, "
P
CERTIFICATE OF COMPLIANCE 0`e,
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby ce{tify [hat the Sewtge Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
f,3
has been installed in accordance with the pro inions of 310 CMR 15.00' (Tide 5) and the approved design plans/as-built plans relating to
application No. ,. `p',dated d »i �t°. /f Approved Design Flow °'a` (gpd)
Installer
nspector: r'4-' 4PgIC0, .ate:^ Date: � !B�• r.+"
1
The issuance of this permit shall not be construe as a guarantee that the °system will function as designed.
FEE � `,: -S
r? ✓`
COMMONWEALTH Of MASSACHUSETTS
Board of Health, a n, d) E'"i HA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at C(, (•.�o' (1 o CAU'- ( � ��• 1 �' f t".� as described in the application for
Disposal System Construction PermitNo. /^ a( ;dated
/ r
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Clarle9m9o,MA c Date Board of Health T�"