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2b D C®MM®NALTII ®F MASSACRUSETTS
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM T j'kW; 2 ',�' 20ZU
Application for a Permit to Construct(Re lir ()UPgrade Upgrade( OCompleteSystem ❑Individual CombntDrfi
Pone.
Location
Owner's Name Wzdt 6� ll ih
Map/Parcel# 40
Address t lY-
Lot#
Telephone# itNCY6• _
Installer's Name
` ev — Designer's Name low() IYI&rl
Address u Jr
n `' Address qj �"tlllh /
Telepl'tone#
' Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS ORALTEF
_ gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
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 agre4 to not tpgggplace the a tem, in operation until a Certificate of Pomlance has been issued by die Board of Health.
Signed `J ! t 4�i�,�V1.7U}✓f,,L,µY1-._ Date _117-11916
Insnertions 2i2(�Z�-` i/' ��'t'1 'rfifl'LI%If Wn � Qlf
0115
No. Gl �"f S.`.(.`3.... a?�§ � FEE �i�', 60C®MM®N LTH OF MASSACHUSETTS t^ •L~6 r.,-:
Board ofHealtly v`48-a.A`' OOnt -' , MA t tt S e .p 01.2:
CERTIFICATE OF COMPLIANCE `"i•r �1 �'
Description of Work: ❑ Individual Component(s) ❑ Complete System r^
The tIIndersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded`' < Abandoned( )
by.
at
has been insralled'in accordance with the provi tons of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No a dated( '
Approved Design Flow (gpd)
Installer ,iik k�1'1
I,C '4� t t �"A 31...
g
Designer: S Y}t"m (Iwp L_ , yf4t$`' Cr ", ^"i``' r , p, .I Date:
Inspector. Z �',�)�, ° ''
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. b
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No t:, 0;'t tt t. „"..(1 -,„�. '111,13V CC (, IWYLI -F, �\WFI(�-,.�t•iAil l FEE 1 .P'd.�d,00
COMMONWEALTH Of MASSACHUSETTS
Board of Health, 1*1 hF r`h'.AWia )° VTl - MA.
DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Permission is hereby granted to Construct( ) Repair( ) Upgrade x' Q, Abandon( ) an individual sewage disposal system
x
at Y `' art'° t w"S 9 ° 6-f (t as described in the application for
_7 rw' r i
Disposal System Construction Permit No. 1,L ` (=- .� , dated 1 11,
Provided: Construction shall be completed within three years of the date of this,permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M.sualnCo. chstledw,MA Date 1 1 r� ! ,' C ,+t( -Board of Health``• °=>�