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1 FEE
S COMMONWEALTH OF MASSAC14USETTS
Board r f Stealth,
APPIKATION FOR DISPOSAL SrrSTIMCONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( Abandon( ) - ❑ Complete System ❑ Individual Components
Location Owner's Name �1
t
Lot# arcd# i Address 126 LA LAYl1 Y t� l MA
l � g
Lot# � I �►Y'1
Telephone# 2
Installer's Name
�O \
l kAfr �1G.� Designer's Name A
Address � � 1 �. 1 A A � Address
Im
Telephone# t V1i1 �1
j 'Telephone# 0.23t�S
Type of Building
Dwelling - No. of Bedrooms ---4-
Other - Type of Building
Other Fixtures
Design Flow (min. required)
r Plan: Date_ ! —
= z c�
. w ,Title
Description of Soil(s)
Soil Evaluator Form No.
v
gpd Calculated design flow_
Number of sheets
Name of Soil Evaluator
Lot Size sq. It.
Garbage grinder( }
No, of persons Showers ( ), Cafeteria ( )
Design flow provided 4 (, gpd
Revision Date
Date of Evaluation
25�j
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees o not to p e e ryatem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed tht, Z �/
��. Date
Inspections -
COMMONWEALTH OL MSSCRUS�,TTS `34�
FEE
Board of Health, r a MA et, I
CERTIFICATL, OF COMPLIANCE �
Description of Work: ❑ Individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( }, Repaired ( ), Upgraded ( ), Abandoned ( )
by: 1 AA t' —
at 2) Tan
has been installed in accordance with the pi- t7s. ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application `Nod-U nit .; dated Approved Design Flow /4 ( d)
Installer Il(`l {((� 1(�
Designer: ! t _ Inspector: Date: U r t
The issuance of this permit shall ndt be construed as a guarantee that the system will function as designed.
'
�' � FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ,�T MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at � � �
_ as described in the application for
Disposal System Construction Permit No,. t/ [x1 dated
Provided: Construction shall be completed within three years of the date ol-1hiemit. All local conditions must be met.
Form 1255 Rev. 51% A.M. Sulkin Co. Charleslmm MA Date h 1 Board of Health �-
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