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COMMONWEALTH OF MASSACHUSETTS
BoardrfHealth,'AtiKIh1Qf�1-W MA.
APPLICATION '0'- DI POSAL SYSTEM CONSTRUCTION 1PERMI� JAI, �o2a
Application for a Permit to ConstructO Repair(l Upgrade( ) Abandon( ❑ Complete System ❑ Individual Components
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Owncr'sName -. L r- caC 6TT
Map/Parcel# / j
Address' :sc.tS1NC Aar O4'.
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Lot# �' e f°p�,!
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Installer's Name 5-7"
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Designer's Name ACCe f`.S -,S ,
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Address (�• n:15
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Telephone# �' 0
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Telephone# '7n!K- SG .- as,, a
Type of Building Lotsize..4 000 sq. ft.
Dwelling - No. of Bedrooms 5 Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixores
Design Flow (min. In 1) .lrte-) gpd CSlculated design flow 5 S f_ Design flow provided _ gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) i
Soil Evaluator Form No,
Name of Soil Evaluator 4-)� Al e l /A, i.' �g_go' Date of Evaluation
RAIEALTERATIONS
SrOR
DESCRIPTZO�N. OF REPAIRS
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The undersigned agrees to costo the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to pla tem jW6peration until a Certificate of CoTpliance has been issued by the Board of Health.
Signed L_ Date /
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No. t.,.»a,., FCL
COMMONWEALTAvOr MASSACHUSETTS
Board ofHealth,
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CERTIFICAIIaE OF COMPLIANCE t 0u_
Description of Work: ❑ Individual Component(s) ❑ Complete System 6 K �(
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (tr')", Upgraded'(., Abandoned ( )
by: E� :S�?tE'_, hw'1: . "'pr' C"o+ 1 l C rn
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has been installed in accordance with Qtejpmvi toils of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.'%(' - <r >c'. cn/ ,dated i f ' 1 P E,() <r f'1 . Approved Design Flow '`, `,P R....? (gpd)
Installer c", 'r $,'>, ju (""" CR)s" - I
Designer: hACr,7 ,^..d ,`,•2,:'.-? "'eS Inspecto: Date: �'. d i �,' � 7 t1I ( ,
The issuance of this permit shall not be construed as a guarantee that `thg„system tvMfuncdon as designed. t
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COMMONWEALTH OF MASSACHUSETTS (Az 111kE 11111�-.�
Board of Health, 6'e'' ll'sOUT-P- , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Permission is herebygranted to; Construct( ) Repair(iv) Upgrade{ Abandon( ) an individual sewage disposal system
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Disposal System Construction Permit No, dated
as described in the application for
Provided: Construction shall be completedwithin three years of the date of this permtU All local conditions must be met.
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Form 1255 Rev. 5196 F.M. Sulkln Co. Ctad¢sitlnl461A Dace .Board of Health •