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16 COMMONWEALTH OF MASSACIIUSETTS
Board of Health, _� �t� "q
APPLICATION FOR DISPOSk SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( Abandon, ) - D Complete System D Individual Components
Location Owner's Nam ��
Map/Parcel# Address
Lot#
Teiephon
Installer's Names
Address Address �fJ rLJO
Telephone# _ Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
_ Garbage grinder( )
Showers( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR Al TERATIONSZ4 'q//Z
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees of tc p the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ,p ,c Date
Inspecuons
No, Li COMMONWEALTII OF MASSACHUSETTS ZZ
FEE
2- 1 /I� /z -�
Board of Health, -top
CGLQ`
Description of Work:
The unde
by:
at
CERTIFIC £ OF COMPLIANCE w�-�- sc�---���e -7
/Individual Component(s) ❑ Complete System Qr1 G-Z Z� �z6 Lam "
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.
y dated . Approved Design Flow (gpd)
Installer -�/'?e5'e<-- /'`tom r f OMP��)� rr Designer Inspector: _ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FEE
'7q //6 COMMONVLTEALT11 OF MASSACHUSETTS
G /'lam L%2r
Board of Health, _
DISPOSAL SYSTEM (ONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair(' ) Upgrade( ) Abandon( ) an individual sewage disposal system
at C�y"S as described in th 1.'
Disposal System Construction Permit No.
ru
//6 , dated & Z�z4
r e app cauon fo
r
Provided: Construction shall be completed within three years of the date of this rmit. I local nditions must be met.
Form 1255 Rev SM A.M Sulkin Cc Chaile MIo MA Date LLA�roard of Health
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