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.a.j; No. � � . � � � � � i C�` / - � 3 FEE � J
i -
/ COMMONWEALTH OF MA SACIIUSETTS
Board r f Health, f/I � h�� AM.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon! ) - l7 Complete System O Individual Components
Location I! : t !. Owner's Name IY14
Map/Parcel# 133 Address
Lot#_ Co Telephone# '+ 19 .FYI
Installer's Name { ` I Designer's Name t' �
Address ,,S J !ei ! "PLw kon-Impa Address
Telephone# �_�f�� ��7 / Telephone#
Type of Building _ -_ 1'�!°F %�� ,/
Dwelling - No. of Bedrooms
Other - Type of Building —
Other Fixtures
Design Flow (min. required)
Plan: Date _0_ _
Title
Description of Soil(s) —
Soil Evaluator Form No.
No. of persons
Lot Size _ L '� sq. ft,
Garbage grinder( )
Showers ( ), Cafeteria ( )
gpd Calculated design flow Design flow pro%rided
Number of sheets Re%ision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree"o not to place, the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _ . _ , _ Date
-mot
s inspections
No. ZL
i
COMMONWEALTH OL MASSACHUSETTS { r�, FEE -LID
Board of Health, , AL4
ff CERTIFICATE OF COMPLIANCE
Description of Work: �llndrvidual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (04pgraded ( ), Abandoned ( }
at ��al SL. s� !�Q Of.has been installed in accordance with the pr.ck. s of 310 CMR 15.00 (Title 5) and the approved design plans,. as -built plans relating to
application No. `, ` n Ci / —, dated ` /'tApproved Design Flow ` (gpd)
i
Installer ,'C ,h, 4
Designer: �� ��� Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed
No.�?�
COMMONWLALTH OF MASSACHUSETTS
Board of Health, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( } Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 4 r X 14 ] I 1 p.iA, — as described in the application for
Disposal System Construction Permit No. �/. nO dated i
rided: Construction shall be completed within three years of the date of this ermit. All local conditions must be met.
255 Rev 5/96 AN Su Dun Co ChAONRMA Date Board of Health
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