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Board of Health, VIA.
APPLICATION FOTO DISPOSAL S'VST]-__,1.I 'CONSTRUCTI'ON PERMIT
Application for a Permit to Constrncty Repair( ) Upgrade( ) Abandon( ) - XComplete System O Individual Components
Location7 D n�.��
Owner's Name ���1�k
_F
At
Map/Pmrcel# 1,:.It -)
Address tee- j 1\; At el <[" • �-v V 111
Lot# (
Telephoneff Yue
.. JrYLi�
Installer's Name Ir.. �i ft � Ic s� ��Y 45
Designer's Name' UF71
I' eLall-a l
Address 0 l_ v4 i u'jcl ,,.1 •' �(� ,�� # �b5
Address
Telephone# `� 2 _Dry
Telephone# h
1 �
Type of Building Lot Size 16, 1 1 Z i') ^ sq. £t.
Dwelling - No. of Bedrooms _;,�j Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Plow (min.. requir
"ed) (� gpd Calculated design floe -_t:14:0 Design flow provided 3 I�' gpd
Plan: Date % U / 3(r / O ) Number of sheets Recision Date / 2 //°/
Title
Description of Soil (s) _
Soil Evaluator Form No
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
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 afire o no t eyhe system in operation until a Certificate ofCompliancehas been issued by the Board of Health.
Signed°°t�i�-�"�� Date / �'� t /-t G
Lasnectioh.s i%)/c"'t5�"Glc 1��+i�°'r !f./U 7(
No.
i2fl w / d7 `2- COMMONWEALTH OF MASSACHUSETTS o'
Description of Work:
The undersigned her
by:
at 5,..) Cilor^Fn
has been installed in a
Board (fHealth, 1` P 4�' / , MA.
C-ITTIFI'CATI1- OF COMPLIANCE
❑ Individual Component(s) Complete System
)y certify that the Sewage Disposal System; Constructed X, Repaired ( ), Upgraded ( ), Abandoned ( )
1)"&(' G V CCAdei cei I - s Tsoa
application No. G(� `t t
hnstaller (� V a (l zN -
ce with file provi: otrys° of 310 CMR 15.00 (Title 5) at� . e�approved design plans/as-built plans relating to
dated 3t C= S« Approved Design Plow vC `'' (gpd)
bry,
Designer 1F')4"V1Inspector: 42e t^' t. "r 4ULC/ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
off' rtccc4' COMMONWE-A' I:I OF MASSACHUSETTS
Board of Health,�✓ ✓ G L t"2 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(X) Repair(
0 74 2 --
Disposal System Construction Permit No. C'
FEE _P
Upgrade( ) Abandon( ) an individual sewage disposal system
dated
as described in the application for
Provided: Construction shall be completed within three years of the date ofhV'RyLgrmit. All local conditions must be met.
Form 1255 Ren. 5196 A.M. Sulkln Co. Boston, MA Date , �'�" Board of Health � "—✓ );ay--"` '