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No. tQ(1' it
COMMONWEALTH OF MASSACHUSETTS
Board of Health, - lk Q/Acl i r H mA,
FEE_
APPLICATION FOR (DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - O Complete System OIndividual Components
Location
Owner's Name
Map/Parcel#
37 //(101
Address 3S , 4a; jpLJ ilk
Lot#
f
Telephone# NP9
Designer's Name ,SSA✓ 0,V✓;ROB AW4,4L.
Installer Name
_
Address
SA( of mm_ 62 S& r
Address 20/ lolino /Ja/lw f.4 /M5AWC
l Telephone#
b 0
Telephone# s6v) .79V - 7dlYf
Type of Building Res Lot Size
Dwelling - No. of Bedrooms_. _ _ _ Garbage grinder ( )
Other - Tvpe of Building A,11 No. of persons Showers ( ), Cafeteria ( )
Othei Fixtures . -
Design Flow (min.//required) 5"70 gpd Calculated design flow __YY _ Design flow provided gpd
Plan: Date i0 / s 2 y Number of sheets Z Revision Date
Title 5:rP+ t G u 1i.A r`w j
Description ofSoil (s) Mt i - COatrs�
Soil Evaluator Form No. Name of Soil Evaluator A YDate of Evaluation 4
DESCRIPTION OF REPAIRS OR ALTERATIONS -:�t MU_ _So; ) ApT �; AJ
The undersigned agrees to_ above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees y��o O J ce system in operation until a Certificate of Comp ' cee issued by the Board of Health.
Signed J Darr
t - - -
Inspections _ - - _ - - -- ---
COMMONWEALT14 OF MASSAC14USETTS bK FEE
Board of Health, 1^ 1'1 MA. r
CERTIFICATe OF COMPLIANCE
Description of Work: 0 Individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( Upgraded ( ), Abandoned ( )
by: -' Tt _ --
at . - � � Ut'l ► �� is � — -
has been installed in accordance with the pro,.isions of 310 CMR 15.00 (Title 5) and the approved design plans,/as-built plans relating to
application No. fir`• I S , (dated �K i, -i Approv 1gn Flow (gpd)
Installer Y4rn�Ia. ,1?
Designer: G, r - (tt Inspector:
The issuance of this permit shall not be construed as a guarantee
- — Date:
will function as designed.
FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, _-_ 1 4` MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is here ygrante to; Construct( } Repair( LV"Upgrade{ ) Abandon( ) an Indivdual sewage disposal system
at �� % F, ��
_- .�. as described in the application for
r
Disposal System Construction Permit NI / dated L. L i
Provided: Construction shall be completed within tbsrr�'Of the date of thi All local conditions must be met.
Form 1255 Rev Sf% A.M. Sulkin Co Cha11E51am, MA Date . _ Board of Health
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