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No.W \J — �4 I �<g —T - 2 1 C)j FEE 1 I Q
or COMMONWEAUR OF MASSACI4USETTS
t l� ��
Board r f Health, \(�� _ _ tY1Q(�, M,q.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) -❑'Complete System ❑ Individual Components
Type of Building S PA I i�2� _ _ I.ot Size �d — sq, ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) —3 30 gpd Calculated design flow Design flow provided _yam_ gpd
Plan: Date IV ;kdc� Number of sheets i Revision Date
Title :T-; i F62 - >f1(i�___1� Js>�L1d.)-tA j b f � Rae.�,..��
Description ofSoil (s) J. T
Soil Evaluator Form No, Name of Soil Evaluator Date of Evaluation
The undersigned agrees to ' e above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no aced a system in operation until a Certificate of Co ,e has been issued by the Board of Health.
Signed �7� / Date % o�
Inspections
ro.���'�� '11� COMM®NWEALTI4 OF Ij �' �1 �E1 0
MYASS
Board of Health, i , lye. 5
CERTIFICATE OF COMPLIANCE !
Description of Work: 0 Individual Component(s){- ~T
Complete System
The dersi�nefi her by ce ry fy tha the Sew ge Disposal System: Constructed acted ( ), Repaired (.Upgraded ( }, Abandoned { )
by: 4 0 o C—
a, iC ►'1 G �.. 111n i . I. I U.. ,-A" ". - -
has been installed in accordance with t�ie�pro/vi�sions of 316 CMR 15.00 (Title 5) and the approved design plansias-built plans relating to
application No. , �ted T ' / / 9 c- Approved Design Flow (gpd)
Installer !/
r
Designer: /� �,� Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No FEE_
COMMONWEALTH OF MASSACRUSETTS
Board of Health, , , Am
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gran ed to; bnstruct( ) Repair(/) Upgrade ) Abandon( ) an individual sewage disposal system
at L _ as described in the application for
Disposal System Construction Permit No. of t / /A' , dated
0
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Provided: Construction shall be completed within ll+iray�f the date of thisRermit. All local conditions must be met.
Form 1255 Rev 5/96 AN Sulkin Co. Challegam MA Date Board of Health
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