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#, No. r J �i'41C y - 1 —74 FEE
f' COMMONWEALTH OF MASSACHUSETTS
Board of Health, -�. MA,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( O Complete System ❑ Individual Components
Location 8 Cr l Owner's Name L e �i
Map/Parcel# 1 -7 Address -
/ OG L614 i ✓ /P
Lot# Telephone# Q �• �G 7 9
Installer's Name E Designer's Name
Address .O 715 S A Address / r
Telephone# 3 a Telephone#
_ y- 7Y
Type of Building —�P.S _ Lot Size /t,, 00 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Tvpe of Building .V
---- .. _ No. of persons Showers ( ), Cafeteria ( )
p Other Fixtures
Design Flow (min. required)'/ gpd Calculated design flow Design flow prodded gpd
Klan: Date z 71 z Z 7 Number of sheets __ _ Recision Date
Title _ ��f�t�Lbrc.�C—'--
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation t / s
DESCRIPTX)• N OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
= further agrees to noj tg,A1a ,stem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �j% Zy - _—
Inspections
COMMONWLALTIT OF MASSACHUSETTS FEE �
Board of Health, � Y1 MA.
CERTIFICATE OF COMPLIANCE Description of Work: QJQividual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ),Abandoned( )
by: , 144il
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans; 'as -built plans relating to
application No. T f• / ?r') ' , dated , „ 7 Approved Design Flow � i . l ( d)
Installer - i 1 f T~T�"'
Designer: /�.4 rn—lellj Inspector: ; -- •. a 0' _ Date:—
r The issuance of this permit shall n td be construed as a guarantee that the system will function as designed.
No
COMMONWLALT14 OF MASSACIUSLTTS
Board of Health, \ \1 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
P�er�missio is hereby granted to; Construct( ) Repair( ) Upgrade ( y— Abandon( ) an individual sewage disposal system
at ! )1 (am t_
as described in the application for
Disposal System Construction Permit No. '1 _ , dated 43L) - cli�
Provided: Construction shall be completed within h. ea s`of the date of this er it. All local conditions must be met.
Form1255 Rev 5/96 A.M. Sulkin Co. ChaftowrLKA Date J- �,Zt){ Board of Health
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