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-No. FEE S. MASSACHUSETTS Board of Health, APPLICATION DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( Repair( ) Upgrade( '(Abandon( ) - Complete System Individual
Components Location Map/ Parcel# Loi# 3 Installer Name m pz..a//' Address Tel ho e# Type ding Dwelfing - o. of Bedro s Otber- T of Buildi g the ixtures Owner's Name Address Telephone#
Designer's Name Address Telephone# No. of persons Lot Size sq. ft. Garbage grinder Showers ( ), Cafeteria ( ) Desig o Plan: Date Title Descriptio Soil Evalua DESCRI gpd Calculated deæflow
Design flow provided (min. re uired) gpd NumUof kheets Revision Date öfsoil(s) r FormNo. ON OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Tin/e 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 agrees to ot to place th system in o eration until a
Certificate of Compliance has been issued by the Board of Health. Signed spection No. FEE COMMONWEALTH MASSACHUSETTS Board of Health, CERTIFICATE COMPLIANCE Description of Work: Individual
Component(s) Komplete System The undersigned hereby certify Disposal System; Constructed ( ) , Repaired ( ) , Upgraded (84bandoned ( ) by: at ccordance with the proxisions of 310 CMR
15.00 (Title 5) and the approved design plans/ as-built plans relating to has been i talled •-22-4, dated • Approved Design Flow application o. Installer Designer: Inspector: Date:
unction as designed. The issuance of this permit shall not be construed as a guarantee that the system NO. 78-2/9 0 77/ Co-mzsn COMMONWEALTH MASSACHUSETTS Board of Health, DISPOSAL
SYSTEM CONSTRUCTION PERMIT FEE SO Permissio is hereby granted to; Construct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system as described in the application for
at Disposal S stem Construction Permit NO, dated Provided: onstruction shall be completed within three years of the date of this ermit. All local c nditionsm t be met. Form 1255 Rev.5/
AM. Sulkin co. Boston, MA Date Board of Health