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No
COMMONWIATII OT MASSACIIUSTTTS
Board of Healrh,Lnn MA.
APPTICATION TOR DISPOSAT SYSITM CONSTRUCTION PTRMIT
Appli.arion foraPermit toConstrucl( ) RePair(') Upgrade( ) Abandorr( ) - ElGomplere System O Individusl ComPonents
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Map,/Parcel#7 //,a<A
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Address
Lot+Tetephone#l i9l-!
Installer's Name \a'c :f\xcp5l Designer's Name ic(T
Address a'b Lr )Addr-ess }ED q\ ab Jarrocuth oaul9
Telephone#Telephone*Y)I
Tlpe ofBuilding Gtr denY,G\l,ot Size ?,.sq. ft.
Garbage grindet ( )Dwelling - No. ofBedrooms
Other - Tlpe of Buildi.g No. ofpersons
-
Showers ( ), Cafeteria ( )
Other-Fixtures
Plan: Date
Design FIow (min leqtrired)
./a/z+/z o
.'' ' t': gpd Calculated design flow Design flow provided 8Pd
Numbdr of sheets Revisio[ Date
>Title
Description of Soil(s)
Soil E\?hla orm No
DESCRIPTION OF REPAIRS OR AIIf,RATIONS
Name ofSoil Evaluator Date ofEvaluation
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Trita //F. I5/A 7s k z<ke
Theundcrsign€dageestoiDstalltheabovedescribedlndividualsewageDisposa!spteminaccotdancewirhtheProvisio,sofTlTl,E5andil;;. ;;i;;.; pr... m" q"* i" "p"".ion untit a certificaL of iompliance has been issued bv the Board of Health'
Signed ... - ..' Date
Inspectiotts
107Or,tDc' zo'c,FEE
No C0MM0NWTALIH 0t MASSACIIUSIIS !,,,,(4..
Board of Health,MA.)At 4/
*<ftl <r'?^tA 14-(.'
CTRTITI OT COMPTIANCT
Description of Wort: 0 Individual Component(s) E Complete Sptem
gy',Upgaded ( ), Abandoned ( )hereby cer.iry that the Ssrage DisPolal S)'stem; Constructed ( ) ' RepairedThe(;4 / 5--tbI
al t42.4,.,
has been insulld in accordance with t-he
dated Approved Design Flow .' (gPd)
of 3I0 CMR 15.00 ('Iitle 5) and the aPProved design plans/as'built plans relating to
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20-zIv
01
applicatio
Installer l\*-Date 1_l
Designer
The of this perrnit shall not be c!-nstrrred as a gurrantee that tie system will function as desigaed.
FEEVNo.
CO},IMONWTAITII OT MASSACIIUSTITS
Board of Health,
I usposAt SYSTIM coNSIRUCIIoN PTRMII
permission is hereby granted to; construct( ) Repair(aJ' upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
MA
at
Disposal System Construction Permit No'dated
Provided: Construction shall be completed within three vears of the date of this Permrt. All local conditions must be met'
l2 Z2
\//5DForm 1255 B.!.5/96 A.M. Sulkin Co ClBdedoin,lilA ate Board of Health t\1
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20 cvlDS IEE
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Owrrer's Name
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