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COMMONWEALTH of MASSACHUSETTS
Board of Health, , AM.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrades ) Abandon ( ) - 0 Complete SystM a Individual Components
Type of Building -_ \ A�P(T�" t 0�. L.f Size 1 _ sq. ft.
Dwelling - No, of Bedrooms --R� : Ao Garbage grinder ('>r
Other - Type of Building t1 �; No. of persons Showers (-r, Cafeteria (t-)
Other Fixtures 1� - t �� ;-L,�-
TTT��
Design Flow (min. required) , -�%�� . gpd Calculated design flow ( Design flow provided 2 . i �_ gpd
Plan: Date Number of sheets Revision Dare
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator , Ic�y,t� a L M Date of Evaluation -,�- Q -,4L L
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 p*e.0e system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ,. Date -1i
Inspections
COMMONWEALTH OF MASSACHUSETTS
Board of Health, , ]►f
CERTIFICATE OF COMPLIANCE
FEE
7
5��:'f�
Desorption of Work: -Wndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade, Abandoned { }
by:
at � I
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..-:l,-/ dated t Approved Design Flow (gpd)
Installer ,i y %r r S L
i
Designer: _ - �" �' �- R. L;.� Inspector: Dace:
r
The issuance of this permit shall not be -construed as a guaraAteedmt-Che system will function as designed.
`~
FEE-
COMMONW ALT1I OF MASSAC14USETTS
Board of Health, Am.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct{ i Repair( ) Upgra40� Abandon( ) an indhidual sewage disposal system
at l as described in the application for
Disposal System Construction Permit No. '-/ C195V , dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev.5196 aM SulkfnCo. CbIdbvgNA Date ?�'1 r)` / Board of Health � � _-
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