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O mW-EOM a. a) 1 Z m Qn, �—10 m 4M —0 oo cQ,,3�-0m COCOA ? 0 tAp a v t*t R rn 0 Cil Qf n m d �o m a No.—?j2�v r FEE J i OMMONWEALTH OF MASSACHUSETTS 2-�7 (° _ C Board of Health, _ Y A-m n ln-" , MA. ICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( - ,dGomplete System O Individual Components Type of Building y / .. �/ i� l Lot Size sq. ft. Dwelling - No. of Bedrooms , Garbage grinder( ) Other - Type of Building No. of persons Showers ` p (), Cafeteria ( , Other Fixtures Design Flow (min. required) _ Plan: Date . Title Description of Soil(s) — Soil Evaluator Form No. gpd Calculated design flow Design flow provided Number of sheets 0 _ _ Revision Date Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS Date of Evaluation gpd The undersigned•agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agitees�to not to.pyla�ce7 the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed /t'.��,, Date Inspections-- �' No.bc,4 VC-15-3 6-10 COMMONWEALTH OF MASV� USI~TTS �� o Board of Health, _ La M n tnnA CERTIFICATE Of COMPLIANCE �s Description of Work: U Individual Component(s) ❑ Complete System �2 G>r1Cc.� " Wr P76 o The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired C ), Upgraded ( }, Abandoned ( } by: •+, r #^ j at 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. dated Approved Design Flow—_(gpd) Installer_E•LAPielK - -- - — Designer: r 2AVss 91J (—::mri , Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. COMMONWEALTH OF MASSAC14USETTS G � Board of Health, V 6� z Mn �) -%.4 NA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is herebygranted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an indixzdual sewage disposal system at Disposal System Construction Permit No. dated as described in the application for Provided: Construction shall be completed within.thi:ee yt wa of the date of this permit. All local conditions must be met. Form 1255 Rev. $/% A.M. SOW Co. Charted mMA Date!' -`// Board of Health AP /F j7i/�'HfGY,/�7. L/laY����sst- r