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Name of Soil Evaluator
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Date of Evaluation
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COMMONNVEALTIJ OF MASSAC14USETTS
Board of Health, , MA.
APPLICATION FOR DISPOSA SYSTUM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (}f!, Upgrade( ) Abandon( ) - 0 Complete System O Individual Components
Location ,Z -
Owner's Name
Map/Parcel#
Address-
Lot#
l Teephone#
1 � S31
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Installer's Name 't
- -
Designer's Name
Address x
Address
Telephone# : /
Telephone#
Type of Building ! f�_ -_- Lot Size sq. ft.
Dwelling - No. of Bedrooms 7,— Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
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Number of sheets
DESCRIPTION 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 not to place th tem ' operation until a Certificate of Compliance has been issued by the Board of Health.
,,?SignedDate
Inspections
No. 1, Z� 2Z�� Q�4 // FEE _ —
COMMONWEALTH OF MASSACHUSETTS 1) , ,U;
Board of Health, Ilt4.
CERTIFICATEbF'
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: -.t- r
at \ -1 1
has been installed in accordance with the proof 310 CMR 15.00 (Title 5) and the approved design plans; as -built plans relating to
application No. o�% dated ] Approved Design Flow AJ (gpd)
Installer — 2 / '/ T A
Designer: Inspector: - J Date: 4 ) ✓ � l
The issuance of this permit shall not be construed as a guarani0e-dttQ'the system will function as designed.
No.. • O kEE'
COMMONWFAIT14 ®f MASSACI-IUSETTS
x
Board of Health, MA,
DISPOSAL SYSTEM ONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (� Abandon( ) an indiNidual sewage disposal system
at _ 27 a l V / (� vc s as described in the application for
Disposal System Construction Permit No. c2 7-off/ , dated �.
Provided: Construction shall be completed within three years of the date offstws4rwit. All local conditions must be met.
Form 1255 Rev 5196 AM $ulkin Co Nde�m MA Date � . ,�; ! d` ,1 Board of Health
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