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No,' '1 1� . 24 • &, FEE
COMMONWEALTH OF MASSACITUSETTS
Board r f Health, I , MA.
APPLICATION FOR DISPO AL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( Repair( Upgrade( Abandon;,) - ❑ Complete System 0 Individual Components
Location ! ��� - -- Owner's Name LV 1 .> j
Map/Parcei# S - Address `70
Lot# Telephone# sQ $ -{�a3 7 -1172
Installer's Name 01, S 46d-19T14ts �Q Ski - Designer's Name � f / � rn lZel Apry
Addressax
3 a �3
Telephone# ,►Slphone# 6 a 94(s ,' lif
-Type of Building ` �/� �'��j�j�/✓'j Lot Size2 / sq. ft.
Dwelh ig - No, of Bedrooms
.0 _ Garbage grinder
Other- Type of Building ! No. of persons Showers ( ), Cafeteria ( )
Other Fixtures _
Design Flow (min. requirear: :?V gpd Calculated design flow —IY51 Design flow prodded d gpd
Plan: Datr k l J ! 1�a" Number of sheets Revision Date
Title +0mgd-1111 41 o /0
Description of Soil(s) -e P S O , r G t
Soil Evaluator Form No. Name of Soil EvaV, f " Date of Evaluation
DESCRIP'i"ION OF REPAIRS OR AI TERATIONS �P S P,, i L
The undersigned a o install the above d 'bed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t place a min ; until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
N. y _ 24. 1`D`6
COMMONWEALTH OF MASSACHUSETT, FEE
Board of Health, _ �G l C' w rh JIM.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ), Repaired Upgraded l }, Abandoned { )
by:at Z 1-; i
has been installed in accordance with the pr Rio of 310 CMR 15.00 (file 5) and the approved design plans/as-built .plans relating to
application!! No. -X `1 i VI(o , dated oar Approved Design Flow, (gpol
Installer t _ 1i `a 12 f01rP' 5 (—,_. ':1 P
Designer L la, �) e '-L. rtL1 Ce!}4.ei_}osp�rw -1/ Date:
The issuance of this permit shall not be construed as a guarantee that the system will functi n as designed.
No. t� C 24 6
FEE J 1
I COMMONWEALTH OF MASSACHUSETTS
Board of Health, oq r� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an indiNiduat sewage disposal system
at /= described in the application for
Disposal System Construction Permit No. , dated - J
Provided: Construction shall be completed within d 7M the date of tYtlwpivmit. All local conditions Hurst be met.
Form 1255 Rev 5/96 A.M Sulkin Co Chetio Mn. MA Date r, Board of Health �! ��
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