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T = COMMONWEALTH OF MA C'14 E��
Board of Health, Gl AM.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) U�grade,(�) Abandon( } - ❑ Complete System 4Individual Components
Location 1$-Ttnuhrr�in. V�a'th 'ti1r ,� Ustrwt,,. if1
Map/Parcel# +60
Lot#
Installer's Name � � B Ow (0
Address _3L3 W�tt�c� 17A-4h Sal.
Telephone# S �q 7 S:,77
Owner's Name R61
Address ZZ_Semtnjk 1DIV
Telephone#
Designer's Name It- Z
Address
Telephone#
Type of Building �(- v%Ae, Ole, ( Lot Size _ 315/, / sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Tvpe of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) _ D d Calculated design flow s,
— gP g /r 3 Design flow prop ided gpd
Plan: Date Ntunber of sheets
�� �t� Revision Date
Title ,, m,4k Kl A
Description ofSoil(s) h Vl 40 (CzcSL n„rj R , ,n iI'l
Soil Evaluator Form No. Name of Soil Evaluator M. ► 1 mp ,1, I Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
r14, /•/ mil /,G////
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Theandersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 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 Date % / / Z-s i`
Inspections
v
LZL4 lQ
No. � 60 � L � FEE
COMMONWEALTH OF MASSAC14USETTS 6 � � �
Board of Health,
CERTIFICATE OF COMPLIANCE L
Description of Work: (Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded), Abandoned ( )
by; rr { c
at 17 TfaAyiA1ir A Uir Amur v I1A
has been installed in accordance with the pr «si s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. � %. dated c Approved Design Flow jyj�-_T(gpd)
Installer
Designer:_/1i,(� r,; Inspector:rAllf Date:_ Ld
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, _ YHp-_L� AIq.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (<) Abandon( ) an individual sewage disposal system
at
_ as described in the application for
Disposal System Construction Permit No. - - 33 1-1 dated /
vided: Construction shall be completed wi i / 4-@ ) n-titsoa.�e�r�,('the date of this pe�All local conditions must be met.
Rev 5/% A.M.SutkinCo c»tvm,mA Dates i Board of Health
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APR 19 2024
HEALTH DEPT.
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