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FEE 5J' GC
ntj COMMONWEALTH OF MASSACHUSETTS
Board of Health, Y6t1rjy\ G 1, / h , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair{?O Upgrade( ) Abandon( ) - O Complete System A Individual Components
Location r
^r D,v('d
Owner's Name J•Ud �,1 f
Map/Parcel#
2� I Z0,3
Address j arold-fvrG1 fol yam®U/k
Lot#
Telephone# -?-3 5- ZZ Z" 2 2 2 Z
Installer's Nameour
IhL✓
Designer's Name
Address L3
v
Address
Telephone#50R-Soy-Telephone#
Type of Building _
Dwelling No. of Bedrooms
Other - Type of Building _.
Other FiXtnres
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
No. of persons
Lot Size sq. ft.
-.._ Garbage grinder ( )
Showers ( ), Cafeteria ( )
gpd Calculated design flow Design flow provided
Ntumber of sheets
Name of Soil Evaluator
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS - 1115E
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TTI'LE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed OL Date .�- - 2 q
Inspections
No. _Zy `-2 V _ EFE S
COMMONWLALT14 OFMASSACHU
Board of Health, �16141)ylh
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System-, Constructed ( }, Repaired (K, Upgraded ( ), Abandoned ( )
by: L0.3 C_.
at t"
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. O .d , dated _ 1 '� Approved Design Flow -P (gpd)
Installer
Designer: t, A Inspector: Date: n —D a I /
The issuance of this permit shall not be construed as a guarani the system will function as designed.
No,
�3H c Z' ?
FEE
COMMONWEALT11 OF MASSACHUSETTS
Board of Health, I1�.CM 6 U lI, . , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( b4 Upgrade( ) Abandon( ) an individual sewage disposal system
at / 1 EffJras described in the application for
Disposal System Construction Permit No. �' G L? dated
Provided: Construction shall be completed within three years of the date of this peUnit.--At}blocal conditions must be met.
Form 1255 Rev. SM AN Sulkin Co. Charldown,MA Date Board of Health � '
• a30LOAL
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