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17 Application & Permit 2012 a! FEE COMMONWEALTH OF MASSACHUSETTS ' Board of Health, ^/G/2%/{Amp/4cMA "LICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT mit to Construct( ) Repair( Upgrade Abandon( ) - Complete System ❑Individual Components LYcE -cell(/7 040 Ate o/2rNfi'+'/ 9o&i AO/ 'shame J W LO] ry %LC Stye " Si a 61 40P 2Y ine uilding S/PFR/77/4/i/10/14, gearoo v'TM MS y of Bedrooms / /9'»'L ype of Building POLL- w /tq :ores G I/9r Design flow provided SO gpd• tier Y/ gp� Calculated design flow to (min."VG Revision Date --- te ✓ t�L 9 0 ZNumberofsheets it Q j F.rre 1 Owner'sNamea/it tiPecole/ Address/7OLa Arrest Designer's Name 1JfttjJffl4 ,^ Address /8 /XAorR6 “4/441-77 s ' OsI L Lot Size �ri5 sq.fad Garbage grinder�C No.of persons Showers(/).Cafeteria We Ion of Soil(s) // Name of Soil Evalua r Lf%`T'SLLEd� Date of Evaluation uamr Form No. ^� jd/I,8 ‘5.• o7; 5// PTION OF REPAIRS OR T�FRATIONS a gree ed agrees to install thetem in operation until Individual eroicatte of Compliance bas been issued by the Board of Health. 5 and agrees�no mpce e. operation gyl.7/L�. Date Lions COMMONWEALTH OF MASSACHUSETTS Board of Health, I / /,i , .2 lo frit MA. CERTIFICATE OF COMPLIANCE on of Work: ❑Individual Component(s) ❑Complete System ersigned hereby certify that the Sewage Disposal System; Constructed ( ).Repaired( ).Upgraded .Abandoned ( ) /< c , ..e instilled in accordarfce with the pmsdsions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to on No. "/—/ i dated c - ,-� Approved Design Flow / /, (gpd) (/../. . IP /` 'ire q - �. — %l�/ 1 e t - Date: ante of this permit shall not be construed as a guarantee that the system will function as designed. FEE r/_ FE r, _>G COMMONWEALTH OF MASSACHUSETTS Board of Health, / MA. n DISPOSAL SYSTEM CONSTRUCTION PERMIT sion is hereby granted to; Construct( ) Repair( ) Upgrade( /) Abandon( ) an individual sewage disposal system /\\ as described in the application for al System Construction Permit No. ( / ) �;1 dated c/ ed: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Rev.5196 A M Su010 Co.CIAMAREA,MA Date Board of Health