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40 o 11L COMMONWEALT11 OF MASSACHUSETTS Lec`c h
Board rfHealth, C
. MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application ff a Permit to Construct) Repair( ) Upgrade( ),Abandon () - O Complete System V Individual Components
Location I yr��
ltifap/Parcel#
Lot#
Installer's Name
Address
i
Telephone#
Type of Building s
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan'0 Date
Title►-.L,
Description of Soil (s)_[
Soil Evaluator Form No.
Owner's Name
Address C
Telephone#
Designer's Name
n 1' -
Address
Telephone#
I.otSize +/
sq. ft.
Garbage grinder ( )
No. of persons , Showers
( ),Cafeteria ( )
gpd Calculated design flow
Design flow pro�9ded Z�
Number of sheet - ! �— gpd
Revision Date
DESCRIPTION OF REPAIRS OR AI TERATIONS
Name of Soil Exalua
�t
*Date of Evaluation IT S
.I
The undersigned agrees — —
further agreesjo install the aboXsdtscrtbed Individual Se ' '-_ "'vf--
to not W place the wage Disposal System in accordance
s�sr4rtn in operation until a Certificate of Co wi h4we Provisions of TITLE 5 and
Signed nipliarece has been issued by the Board of Health.
------ _ Date -
Inspections
No. " / / /
COMMONWEALTH OF MASSACHUSETTS FEE
Board of Health, I i
Description of Work:RTIFICATE OF COMPLIANCE
ClC l Individual Component(s) W'Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (—<Repalred ( ), Upgraded Abandoned
at ( )
has been installed in accordance with the protjsions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
, �/. �c, /,
dated Approved Design Flow g P /as built plans relating to
application No.
Installer g �_(gpd)
Designer:
The issuance of this p r n —Inspector �— ------ --- __
permit shall not be construed as a system will f_ Date: --
guarantee that the
unction as designed.
No
COMMONIATE�LTH OF MASSACHUSETTS FEE___--
Board of Health,
-----�.,- i=— MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ( ) an indit7dual sewage disposal system
Disposal System Construction Permit No. _ - _ as described in the application for
dated ���
Provided: Construction shall be completed within
of the date of Sb.A�q Co CtT
1255.Rev 5/98 A�P1 ' All local conditions must be met,
CcANhaAes�awrt,MA - - —
Date Board of Health - -
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