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691 Application & Permit 1998"pai atiun Cm FEE I ✓ COMMONWEALTH ®E MASSACHUSETTS Board o/Health, CWRrNAPI PT OA) MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit to Construct( Repair Upgrade( ) Abandon( ) - O Complete System yy Individual Components pc of Building �'7 welling.No.of Bedrooms pe / --5/64J X0/1 3 tiler-Type of Building tiler Fizmies esign Flow (min.required) 3 gpd Calculated design flow Number of sheets ne an: Date itle 5 D, 5 z..-e,:ripiion ofSoil(s) l.�u • • Fs d S S _ n, til Evaluator Form No. Name of So No.of persons 4 Lot Size 250 sq.ft. Garbage grinder(Hd Showers( ),Cafeteria ( ) Design flow provided 4' / 5 gpd Revision Date Date /3 ern Evaluation 3/2 ti 4 p ES(:RIPTION OF REPAIRS OR ALTERATIONS he undersi ether agre OPP 'pet duns all the above described Individual Sewage Dis osal System in accord the systeht in operation until a Certificat- .f r om G we h been i • 14\1` Owner'sName�'RA 16 DMU(5 Address 6,9/1eE37i4Mp7OU RMP AIOeTNAmProO A uion l 11 'Parrcl# /2- / %6 Telephone# 9/3- sr6 - r$53 0/oroo Designer's NameD9u/D F KFATES Installer's Name 3 / ' t..1.44 Address Address/07 Ru5SE/J ST SOS,Lab,414 0/375 Telephone# 'J Telephone# / /3_ 665-- 7670 pc of Building �'7 welling.No.of Bedrooms pe / --5/64J X0/1 3 tiler-Type of Building tiler Fizmies esign Flow (min.required) 3 gpd Calculated design flow Number of sheets ne an: Date itle 5 D, 5 z..-e,:ripiion ofSoil(s) l.�u • • Fs d S S _ n, til Evaluator Form No. Name of So No.of persons 4 Lot Size 250 sq.ft. Garbage grinder(Hd Showers( ),Cafeteria ( ) Design flow provided 4' / 5 gpd Revision Date Date /3 ern Evaluation 3/2 ti 4 p ES(:RIPTION OF REPAIRS OR ALTERATIONS he undersi ether agre OPP 'pet duns all the above described Individual Sewage Dis osal System in accord the systeht in operation until a Certificat- .f r om G we h been i • N„ / (-7 COMMONWEALTH OE TASSA ,TIUSETTS FEE �, Board of Health, L aQ rotifrvi !J , MA. CERTIFICATE Of COI PLLANCE Description of Work: )(Individual Component(s) 7 Complete System The undersigned here certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) by: aCl(si 1...)41)) s at fe J wt c7-7.4.42...441 rkm a Ask has been r Iled in accordance with def.pi( ioi of 10 CMR 15.00 (Title 5) and he o9prored design plans/as-built plans rela application No. ylated rs ! . Approved Design Flow J7S (gpd) Installer J/�1,4, f/l4- ,e 4 /- Designer: ThAt.; E KiPi' °f Inspector: r 7 i'� � -ti1 n Date: 3/ 7/ ' The issuance of this permit shall not be construed as a guarantee that the system will function as designed. C// c' FEE/ 9 G COMMONWEALTH Of NASSA ITSETTS Board of Health, l( DISPOSAL SYSTEM CONSTR- CTION PERMIT Permission is hereby granted to; CCoystruct( )/Repair((/ Upgrade( ) Abandon( ) an individual sewage disposal. at @ ( 1J CAA C1/241,i 4jm rY' jF as described in the applicath Disposal System Construction Permit Nc ' is-SY ,dated 5�yi/1 Provided: Construction shall be completed within three years of the date of this p qI'mt All loca con nymust be Form 1155 Rev 5/96 AM_sultln Co Boston.MA Date 0/1;2/Board of Health �� /L