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No. 2_ . 2 21
� FEE
COMMONWEALTH OF MASSACHUSETTS
v l� �� Board(f Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct(; Repair( ) Upgrade( ) Abandon( ) - 0 Complete System ❑ Individual Components
Location 2b �� t ter���r Sa.�P
Owner's Name -
Map/ Parcel# /
Address Z5
Lot#
Telephone#
Installer's Name F — _
Designer's Name $ ( u0
Address
Address c�, jlI
L &ACA AMC
Telephone#
-����f
Telephone*'
I
Type of Building
Dwelling • No. of Bedrooms
Other - Type of Building
ti Other Fixtures
Lot Size r1' %� 7 �— _ sq. ft.
Garbage grinder { )
No. of persons Showers ( ), Cafeteria ( }
Design Flow (min. required). gpd Calculated design flow 3 �9 Design flow provided gpd
Plan Date ; Number of sheets Re -vision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS _�A l ( I i �
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrt to PIT
th to ' .operation until a Certificate of Compliance has been issued by the Board of Health.
Signed i iDate Z
Inspections
No. � � ' 2 3 Z2-i i Q
COMMONWEALTH OF MASSACHUSETT§ dt FEE 1A-
Board of Health, , MA. /
CERTIFICATE OF COMPLIANCE
Description of Work: U Individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
at _,)laieLli.uti - -- has been installed in accordance with the proiisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated i /ot, i . Approved Design Flow j�l (gpd)
Installer 7� r ,p ( ✓l L
Designer: �Sl (�',,,�u�_ Inspector; Date:
—� The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �✓ ZZ I7 FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM _ONSTRUCTIONT PERMIT
Permission is hereby granted to; Construct( j Repair( ) Upgrade( ) Abandon( ) an indivdual sewage disposal system
at as described in the application for
Disposal System. Construction Permit No. .��_ u ; ,dated !, ,Z t-nif / .
Provided: Construction shall be completed within three years of the date of this -mit. All local conditions must be met.
Form 1255 Rev 5/96 0.M. Sulkin Co CWkq#7 Ma Date ; --Board of Health
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