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No. P�DbF'11G"I`l—(YJ48 .� �y- r ,��„/ ��t
coz COMMONWEALTH OF MASSACHUSETTS
I
Board /fHealth, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair(/ Upgrade( ) Abandon( ) - ❑ Complete System
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ITT 097019
Components
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Location ,��,- �
(�, MlSuhn
Owner's Name
Map/Parcelll —3
6
Address
Lot# ;
Telephone#
Installer's Name 5(..�;�
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Designer's Name
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Address `k'3 6
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Address �Y,�
(J�� S.L"S,t,
Telephone#
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Tclephone6 �,
j{5y.t
Type of Building Lot Size -I 4-(, 2(�- sq, ft.
Dwelling - No. of Bedrooms Garbage grinder (/YD
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (ruin. required) gpd Calculated design flow ��--� Design flow provided gpd
Plan: Date �'t' 2.7 I I rl Number of sheets 1. Revision Date
Title
Description of So�iil(s) _
Soil Evaluator Form No
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR AI TERATIONS
Date of Evaluation
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 pla a the systemin operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �2 Date ICt 11!5
Inspections
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No t^")"1 bEt 1 W (7•-p e., FEL
/s ._ COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y!LLij o t rat MA.
CERT IFICNIK OF COMP
Description of Work: t1 individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired,(-), Upgraded ( ), Abandoned ( )
by: 3c ,�
at '- rr ,r Lt tit 0A
has been installed in accordance with the proYisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No..Pt '"%) td' ,dated l) •' e & f Approved Design Flow f� (gpd)
Installer `'� t+✓L °»--c_,o.\dd`._.
Designer:Ur' I�rj� t"'onJrKe..n r,. g inspector: n N A i _.�-, .� Dam,
The issuance of this permit shall not be construed as a guarantee dint the system will function as designed. )'
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No. 4�9C _ (i 3`� �;.., . _ > C_ 0 Cr `yt -G`t F^3 '--- FEE 11 S?;°
COMMONWEALTH OF MASSACHUSETTS
C ( f;72 pl, n Ljrll MA.
y`) "arli ° / Board of Health,
�" DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repaid{✓) Upgrade( ) Abandon( ) an individual sewage disposal system
at 7 e « > . (_,, , r" r6 as described in the application for
Disposal System Construction Permit No. ,e o f , dated // . h.M
g �
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1256 Rev. 5/95 A.M. Suikin Co. Craf[eaee KA Date z°, 'F -e b, Board of Health 1 =, (iX� . \+"•n"°��