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COM ONWEALTH O�FjjM[ASSAC14USETTS .
Board (?f Health, �'u � M VSZ
APPLICATION FOR DISPOSAL SYSTEM
Application for a Permit to Construct( ) Repair(:/upgrade( ) Abandon( ) -
FEE
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location 22 3r. -
- - Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Nam� L' ''
Designer's Name
Address- �-
Address.,..^ -
Telephone#
Type of Building /'/':....-,./ i, .%, , ✓rr Lot Size
Dwelling -No.of Bedrooms
Other -Type of Building No. of persons
Other Fixtures
sq, ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required)/%gpd Calculated design flow Design flow provided / d? z` -i gpc
YLm: Date /% a.i �i 9 Number of shee s _ 2 Revision Date
Title
Description of Soil (s) .��r � -r -✓ -Za �r
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORAITERATIONS�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 to place the system in operation until a Certificate of Compliance has been issued by die Board of Health.
SignedDate
M' E
No. FCE 06
COMMONWEALT14 OF MASSACHUSETTS^
Board of Health, 1 2-l'AE31)T—W MA. f"41e
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑'Complete System �r
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (-); Clpgraded ( ), Abandoned ( )
has been installed in accorda ce with the provis}�ns of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
1'�' it"'`� 2 1I 171"70. Approved Design "? d
application No. � t, � ^ ,dated pp � g (gp )
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Installer 12f§'1)a UI/ fh"t' I�IQ
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Designer: e1 ()alp) (Aft C.'.'h,)61 M e Inspector t:r" _^ Date: i I "i (a<• 7",-,
The issuance of this permit shall not be construed as a guarantee that thei §ystem wifl function as designed.
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COMMONWEALTH ONWEALTH OE MASSAC14USETTS a^���c
Board of Health, Y 9f�,l1B13l l)— MA.
A
DISPOSAL SYSTEM CONSTRUCTION PI ERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No.'? l) " �) �? > , dated ) ! l> :7 0
Provided: Construction shall be completed ryithin three years of the date of this perimt All,locai. onditions must be met.
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Form 1255 Rev. 5196 A.M. Sorkin Co.ChadenerhIA Date ` 11'� � ` `�' Board of Healtli--