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33 Application & Permit 2009 COMMONWEALTH Of MASSACHUSETTS Board of Health, APPLICATION FOR DISPOSAL SYS / CONSTRUCTION PERMIT ion for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑Complete System ❑Individual Components FEE ✓' Lot Size W.f• ' -Noing Garbage grinder( ) gype .f Bedrooms ng Type of Building No.of persons Showers O,Cafeteria( ) Fixture's Flow (min required) gpd Calculated design flow Design flow provided gpd )ate Number of sheets Revision Date Pion of Soil(s) ablator Form No Name of Soil Evaluator Date of Evaluation _ �bd aPTIOS OF REPAIRS OR ALTERATIONS ••!....011. MIA rdersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and r agre s t of to • ce the system in o•e anon until a Certificate of Compl ce has been issued by the Board of Health. nm / Iv%n9 nn te-, .. -saeot-EroK%3K.AS Aeon,. L vs � _33 Parcel# ' ��S FoO°XIGII tti 1 Cal. :gym, 310-V9- 2 ;/ q ler's Name G¢. , . Desigver's Name ess 3 q fl''/c'/ ! J Address ✓ hone# [// 3 cj Gf �/ Telephone# Lot Size W.f• ' -Noing Garbage grinder( ) gype .f Bedrooms ng Type of Building No.of persons Showers O,Cafeteria( ) Fixture's Flow (min required) gpd Calculated design flow Design flow provided gpd )ate Number of sheets Revision Date Pion of Soil(s) ablator Form No Name of Soil Evaluator Date of Evaluation _ �bd aPTIOS OF REPAIRS OR ALTERATIONS ••!....011. MIA rdersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and r agre s t of to • ce the system in o•e anon until a Certificate of Compl ce has been issued by the Board of Health. nm / Iv%n9 -6 COMMONWEALTH ©FF/MASSACITUSETTS Board of Health, /i/v2 Lf'� l MA. CERTIFICATE OF COMPLIANCE ion of Work: ❑Individual Component(s) 'l Complete System ersigned hereby certify that tl Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ).Abandoned 0( 7 0 0 l-i-I"0 7 ¢a 3 3 r. 7.4.A- i FEE'J G installed in accrdance with the provisions of310 CMR 15.00 (Title 5) and the approved design pia on No. "r,”.- dated . Approved Design Flow (gpd) G gt Inspector: once of this permit shall not be construed as a guarantee that the em will function s/as-built plans relating to Date: designed. COMMONWEALTH OF MASSACHUSETTS Board oJHcatth, /tiZ/?%/cse-`•--, 24 MA. DISPOSAL SYSTEM CONST{'UCTION PERMIT lion is herebygranted to; Con truct( ) Repair( ) U al System,Construction Permit No.cG*-- 2 dated FEE 6) pgrade( ) Abandon(X an individual sewage disposal system as described in the application for ed: Construction shall be completed within three years of the date of this permit. All local conditions must be met. iev.5/96 A.M.SuIkin CoChalelun MF Date Board of Health il^^