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No. �1 FEE
COMMONWEALTH OF MASSACIIUSETTS
Board of Health, 1 AM.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
'i.-
Application for a Permit to Construct( ) Repair()() Upgrade( ) Abandon( ) - O Complete System Ol Individual Components
Type of Building _�)t S
Dwelling - No. of Bedrooms �3
Other - Type of Building
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR AI TERATIONS
_ Lot Size sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
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 agr�ealo not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _ Datc
Inspections
61' B/l
No. _ ,, FEE k
COMMONWEALTH OF MASSACHUSETTS
Board of Health,_ Afq
CERTIFICATE OF COMPLIANCE
Description of Work: I Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: _
at has been installed in accordance with the pro psi ns of 310 CMR 15.00 (Title 5) and the approved design plans, as -built plans relating to
application No. dated i o Approved Design Flow _ , ,;, (gpd)
Installer _
Designer: Inspe TC or: Date: t/
The issuance of this permit shall not be construed as em will function as designed. —�f--
No. r -1 ,
COMMONWEALTH OF MASSACHUSETTS
Board of Health, _ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at \ (, 1A Q i �A as described in the application for
Disposal System Construction Permit No. 62V doff, dated l ) .
Provided: Construction shall be completed within three years of the date of this permit. All local conditions mast be met.
Form 1255 Rev 5/96 A.M. Sulkin Co Charles m, MA Date ry Board of Health
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