App-Permit-ComplianceNo. r-� ®� 1 y, l q o/ 2, 5 FEE
COMMONWEALTH Of MASSACHUSETTS
r,A
Mu aw
l/z/ � Board of Health, ���/k2iVlC5l�� , MA.
APPLICATI®N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
? A plication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - 0 Complete System ❑ Individual Components
U
ocation
00
ro C z-
Zamz
Owner's Name
Am L -'$ he,/1 kr
ap/Parcel#
Address =,)4j0
Lot#
Telephone#
C,0-476 �LjG v
Installer's Name*
Designer's Name
�,� Q C✓ r
Address
IJS�r-
G
DaX 7,Z V
S
Address 1003
S, -4%C ki 4 t • o9- 9e^%,
Telephone#
'77-) .
3 4 YO)
Telephone# s'p
.
Type of Building g-eso'd e'^-A.,j Lot Size S O ! J 53 ey sq. ft.
Dwelling - No. of Bedrooms iw e Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) _ �9 C/ gpd Calculated design flow 9 Design flow provided 'W to `%� gpd
Plan: Date ;An- 9. Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 170S-1- // n^✓ yelp 7-i r k,.4 ki
ran44 S - S �-e (QfG✓1
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Co npli ce has been issued by the Board of Health.
Signed Date
//
Inspections .�.
III/qIIIYlq j o S f isv)C
C VC.
No. �� /�J i`� FEE
COMMONWEALTH Of MASSACHUSitTIV
Board of Health,01\ tJMA
CERTIFICATE OF COMPLIANCE �
Description of Work: ❑ Individual Component(s) A-Gomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ((a Abandoned
'Ai
( )
by: -P,,- r L 4 not Coo '4✓6/
„{-, ` VC-gG �
at . l bC;iSr, �'�,- C b,o
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /` lG dated -3 . Approved Design Flow(gpd)
r
Installer .a
Designer: SL. Inspector: Inspector: !%� _ Date:
The issuance of this permit shall not be construed as a guaran ee that the system will function as designed.
No. �/ c� / - FEE f!
COMMONWEALTH OF MASSACHUSETTS
Board of Health, N a12T M n % lTi , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is herebyggranted to; Construct( ) Repair( ) Upgrade.(x)- Abandon( ) an individual sewage disposal system
at G U SO•r Vn / as described in the application for
Disposal System Construction Permit No. �� `�(� 3dated 6
Provided: Construction shall be completed ^within th-re, ze of -the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Health `�