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Board of Hcalth, _, MA tr/t7
APPTICATION TOR DISPOSAT SYSTTM CONSTRUCTION PTRMIT
Applicati for a Permit to Construct/f Repair( ) Upgr-ade( ) Abandou( ; -y'tomptete System O Individual Compouents
Tlpe ofBuilding rlsi*lW q.r..
3D\r,ellirlg - No. of Bedrooms Garbage grinder ( ) ,other.Ty6eofBrrildinsNo.ofpersons-Showen()'Cafeteria()
other Fixfrres;.*"I ,
Ptrn, ootd 6/3/09 Numbdr of sheea I Revision Date N/A
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Lot#
Address
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Telephone#
Telephone# 945-535C
Ad<lress
I)esigncr's Narnt:
Map/Parcel# 1 09
DESCzuPTION OF REPAIRS OR AT:IERATIONS
The agrees to install the above described Individual Sewage Disposal Slstem in accordance with the provisions of TITLE 5 and
es to not to place the srrstem in operation until a of
iltc
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has been issued by the Board of Health.
Signed
Inspectior'rs ZiJ o4s tl
Ni,og /&.,./.6l^-///.FEE
Adaa
COMN,IONWTATTII 0I MASSAC IIUSEITSz 14 14c0t'>o S
Board, of Health,lvL4
CIRTIFnCATI 0F C0]vlpl_lAl,{Ct I L
Description of Work: O lndividual Component(sy d6omplete Sysrem
The ed hereby cerrify thar tlte Disposal System; Consrr-ucted pgraded ( ), Abandoned ( )rbv:
at
wirh rhe ns of CMR 15.00 (Tirle 5) and rhe design plans/asbuilt plans relaring to, dated -2 Approved Design FIow
Designer:Inspector:te
The issuance of this permit shall not be construed as a guarantee that ttre slstem will function :rs designed,
No o7-/?r ,1/5at, /z/ t
COMMONTVTATTII Of MASSAC
FEE
HUSETTS / tu€b)
Board oJ Health,
is hcreby granted to; Constr-uct
Syste
:Cor.rstruction shall be completed wi
m Construction
/.tu)9.of the date ofthis permit. All local condidons urust be
ITA
Permission
u, /7
Disposal
Provided
Fom 1255 Rsv
DISPOSAI- SYSTTM ONSIRUCIION PTRMIT
( ) Upgrade( ) Abandon( ) an individual sewage disposal system
No. rl?/?/, datea 7 'as described iu the application for
Re
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5/96 A.M. Sulkln Co. Cmriedojm, l,lA Date ^/t Board of Health
Inet.
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IDsrallef s Name r];} Tt4-r,-l;tff'rt*-E'Ez:i
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Description ofSoil(s)
SoilIvaltr4t<rrFormNo.-NameofsoilEvaluator-DateofEvaluation-
I
,2
t
HA/.u-r'J
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has been
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