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FEE
COMMONWEALTH OF /MASSAC14USETTS
Board r f Health, IQ f U»%t'I MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairO Upgrade( ) Abandon ( ) - ❑ Complete System ,6 Individual Components
Location lS2ht/�j✓ra, 1Ne� f t a �!
J Map/Parcel# (%v
Owner's Name /Qv
Address
Lot#
Telephone#
Installer's Name b7 r �d
Designer's Name
Address ��b3 &�jlk) /7f� � �/
Address
Telephone#
Telephone#
Type of Building ke31/✓ 4I
Dwelling - No. of Bedrooms _ .3
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description ofSoil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil ENuluator
Lot Size
. c�f persons
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow pro%ided gpd
Re,,ision Date
Date of Evaluation
DESCRIPTION OF REPAIRSORAITERATIONS /lira%6GC Cit'/]f7r'/7 ;1.�h!'-�Bir %t� �rtUc/ �HZ� -7Zd
�llt/ lj''/>Lf7t i/
The undersigned agrees�9,ihslall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees�Eo dot Wn bce the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date _ Z
Inspections
i
No.FEE
COMMONWEALTH OF MASSACHUSETTS , )
Board of Health, 4 MA.
S /5 c t
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired �h, Upgraded ( ), Abandoned ( ;
by: e _ , a
at / Uc iL� OZG
has been installed in accordance with the pr 11isi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.,�/ bq3 dated Approved Desi n Flow (gpd)
Installer
Designer: r' Ins
g Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
N. L-2-� ' (( -I FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, _ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ') Upgrade( ) Abandon( ) an indi,,zdual sewage disposal system
at /Sl� �aW !h✓/f:ji .� y� 411/ as described in the application for
Disposal System Construction Permit No. n?L- )31 dated i
Provided: Construction shall be completed withi *a f f the date of this permit. All local conditions must be met.
J
Formt255 Rev.5196 AN SulkinCo GhadelmA MA Date_�Board of Health
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