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No. �� ' ID� FEE
D D COMMONWEALTH OF MASSACHUSETTS
Board of Health, L ZYY1 22 MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Consu-uct" Repair( ) Upgrade( ) Abandon( ) - Cl Complete System 0 Individual Components
Owner's Name
Map/Parcel# -�
Address
Lot#
Telephone�� • ��C
Installer's Name -
Designer's Name 1
Address
Address
Telephone#
Telephone#
Type of Building
Dwelling -No. of Bedrooms �S
Other -Type of Building
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date _ Number of sheets
�_- Lot Size sq. ft.
.4 Pai;bne grinder_( )
No. of persons .Show�( k` ,'Cafeteria ( )
Design flow provided . , ;_ gpd
Revision Date
Title — _ •- ► �--�- -- .L..—� -- p -�� f --- f
ti
Description of Soil(s)'
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
—7-
DESCRIPTION OF REPAIRS ORAITERA'TIONS 4,! - C.�/
%ar�S� fsS 2s /If
NThe undeWMed agrees to ins t* above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agues to Oot to pbtc a "ern in operaBpn until q Ce*rdficate of ce has been issued by the Board of Health.
Signed _�; _ 1'' - ���� _.. Date {'
¢ 1
Inspections
No. .2 V - 66c>3
COMMONWEALTH OF MASSACHUSETTS
Board,gf Health, ,IIZ2�4r.y .X , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 16 Individual Component(s) O Complete System
The undersigned hereby certify that the
by:
at
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FEE
Disposal System; Constructed ( ), Repaired (), Upgraded ( ), Abandoned ( )
has been installed in ac ord4pce with the provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design now _ (gpd)
Installer } fir
Designer: �- = Insr%cctor: Date: y
The issuance of this permit shall not be construed as a guarantee that the system Will function as designed.
- k _
z FeE _
.� )v OF Us I COMMONWEALTH OF MASSACHUSETTS
Y!k i i 14x i i K.A `
�k H Vl 1 Board of Health, � �, 042i_ Mt
ida f lo3 v` (y/ j�us-� DISPOSAL SYSTEM CONSTRUCTION PERMIT
!�, urcA.
Permission is herebygrianted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at— p I G I 1j_� Drwim. — as described in the application for
Disposal System Construction Permit No , dated _ .
Provided: Construction sliall be completed within three years of the date of this peryait. All jocad.conditions must be met.
Form 1M Rev-5% A.M.SulkinCo.ChaAestad4MA Date _ Board of HeaA `�l rl� t
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