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No. �t-1�_2L U-, (P FEE
COMMONWEALTH OF MASSACHUSETTS
Board r f Health, \'L� c Mr � MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - O Complete System ❑ Individual Components
Type of Building y\
L 1 lot Size L ► �lZ� sq. ft.
Dwelling - No. of Bedrooms _ _ _._ Garbage grinder( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( }
Other Fixtures
1)esign Flow (m` in. relquired) �1�� gpd Calculated design flow
Plan: Date 3 1�_� f 7 o1 L'% Number of sheets
Title► ke ) )Ae ?kf—,M tilt- 4'-11
Description of Soil(s) L
Soil Evaluator Form No.
Name of Soil Evaluator
..
Design flow provided gpd
Revision Date
, \ V\,\
Date of Evaluation
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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _ Date
Inspec tious __ _
No. 21-( . ( (Q
COMMONWEALTH OF MASSACITUSETT 6 �t� FEE
ir��--Lst
Board of Health, ,�_ ]► fA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) O Complete System
The_undersigned hereby certify that the Sewage Disposal System
by:'� X
r `
at 3 -1 C t-\
Constructed ( ), Repaired O, Upgraded ( ), Abandoned ( }
has been installed in accordance it the pr ��s' ns 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 C P
Designer: Inspector: _ Date: 1A14
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH Of MASSAC14USETTS
Board of Health, �Ir ���,� � MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE I D
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at t �1Y-.- _ 1 A d- VxG p \ �y as described in the application for
Disposal System Construction Permit No. c — 7 ", dated
Provided: Construction shall be completed withi °Y' f the date of this permit. All local conditions must be met.
Form 1255 Rev 5/96 AN Win Co. CtorWwRMA Date`' ' Z X)'.I Board of Health
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