670 Disposal Construction Permit 11-3-19 Co, n, o j aalth of Massachusetts
-. . CIty! 1 owp of Number
_ Disposal System Constrluction.Permit
Fora 2A.
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DEP:has provided this form for use by local Boards of Health:Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,Check with
:the local Board of Health to determine the=form they use.
'Permissian:is hereby:granted to:
Nhen iiag out =fi a.r\K to i i W G. 0 u M4 i� �'i 1�Ct, rQ?c�:V i n
forms on the
Name' Name o.Epany:
computer,use G O f 74 6 013:7
only the tab key Address
to move your ()'C'( :lt. Nlt i . .
ssthe return.. 7
uCaypfown State. Zip Code
sl3.t _
ked`
to-perform-ft following work on an on-site sewage disposal system:
❑ Construction
Repair or replacement
ri ❑ Repair or replacement:of system-components
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to
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Facility Address �J
CayfTown !. State Zip'Code
L)m
Owner Telephbrie Number
E
The work to be performed is further described in the Application for Disposal System Construction
Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local-provision:
or special`conditions:
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InSpe,c�hDin 5-
All construction must be completed within three years of the date below.
eet 13 11
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Approved LI ��- tate �-
Title
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