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20.2ZCOMMONWEALTH OF MASSACHUSETTS 0'1`ic5 .
Board of Health, yAh20 O l - , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( /Repair( ) Upgrade( ) Abandon( ) - id Complete System O Individual Components
7 Location 7 6,ffer Lel 4 a Owner's Name Ca ,[ /
Map/Parcel# Address
Lot# /1 Telephone#
Installer's Name /4, (, 6.1"f2/� Designer's Name /.- t�'/;/Q�
/A, // l l v.,l L ,j/ 'n
Address l 4 _I L `j '1i S. 4 ikii. t!4 Address e„4 13 ' W 1�1/M�✓!t. 4
Telephone# 4-c,g'_ J(). al ! Z Telephone# 51.6 ,
775- 17Jc-
Type of Building Lot Size sq.ft.
Dwelling-No.of Bedrooms 3 Garbage grinder( )
Other-Type of Building No.of persons Showers( ),Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 36 gpd Calculated design flow Design flow provided 4S gpd
Plan: Date q- 2-
"7--ONumber of sheets / Revision Date
Title
Description of Soil(s) See' 9/4 J
Soil Evaluator Form No. Name of Soil Evaluator �Q,o,it (1//q/ Date of Evaluation 9 3 7,0
/I �
DESCRIPTION OF REPAIRS OR ALTERATIONS ,el"� e,�ravt�
is- ,
1
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 ce the syst in operation until a Certificate% Z pliance has been issued by the Board oL
Signed �����!��1� ` Date 9 - �J � L���/L'J
SEF 13 1020
Inspections
HEALTH DEPT.
N" �� ZD 0311 FEE%
COMMONWIALTII OF MASSACHUSETTS
Niykam0 is:Board of Health, U , MA. '.a /., '-
CI:RTIFICAT 'I ' , '4
F OF COMPLIANCE �`
Description of Work: ❑Individual Component(s) Complete System
The undersigned hereby certify th[atl�the Sewage isposal Syste ; Constructed K,Repaired ( ),Upgraded ( ),Abandoned ( )
by: .8�1e 1 / 544'i -r/l7G r"
at 7 l-t,tier L H
has been installed in accordance with the proviso qo C14 2 15.00 (Title 5) and e a proved design plans/as-built plans relating to
application No. ZD -2--2--- d ted / $proved Design Flow 3'f (gpd)
Installer /I 1 e ,9 r -, l
l • r
r
Designer: , 's i' Inspector: tj t�-,iv�,, Date: i f�j 1r i 2.-L7
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