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ZO - O215 COMMONWEALTH OF MASSACHUSETTS
Board of Health, V",M DI " , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
FEE $65- OD
11�,N 13 ?0?0
Application for a Permit to Construct( ) Repair(>( Upgrade( ) Abandon( Q Complete SysteT�qudividual Components
Location ---V; �JaCCL�wnr,Owner's
Name C aA1 1�.N
Map/Parcel# 14-7 3
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address'3- 0&
Address
Telephone# -r`),R%4 -�
Type of Building —
Dwelling - No. of Bedrooms
Other - Type of Building —
Other Fixtures
No. of persons
Lot Size � i cr–C) sq. ft.
Garbage grinder (di
Showers Q/Cafeteria (�/
Design Flow (min. required) _ gpd Calculated design flow Design flow provided — gpd
Plan: Date Number of sheets AlI Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned es to in ih bo cribed dual Sewage Disposal System in accordance with the provisions of TITLE 5 and
re tr
at to -a
further agrees of t P31. Certificate of Compliance has been issued by the Board of Health.
Signed Date.
Inspections
N.,
FEE
:
COMMONWEALTH Of MASSAC14USETTS
BoardofHeaUh, AIA. V"',
CERTIFICATE Of COMPLIANCE
Description of Work: ,,, ' '0j,dividual Component(s) U Complete System
The undersigned Ittrehyfertify that the I Sewage DisposaltSy stem; Constructed Repaired k`e ), Upgraded (, ),Abandoned
Y�, V
by: IL
at t7"t
has been installed in accordance with the rovisiops of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated {'j, as Aj
Approved Design Flow
(gpd)
Installer
Designer: Inspector,, Date
The issuance of this permit shall not he construed as a guarantee thatthe System will function as designed.
No
FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair('_/')� Upgrad6f._.)'' Abandon( )an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit,/'All local conditions must be met.
Form 1255 Rw. sm &M. Sulkin Co. Chdeftwk MA Date Board of Health'