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No. �✓Z�. " 1 1 6 41S3 S
COMMONWEALTH LTH ®f MASSACHUSETTS
FEE
Board of Health, Y (c_i14D lam} , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System D Individual Components
Location W i Asrok)^
Owner's Name G
Map/Parcel# 0
Address
Lot# 0,1
Telephone#
Installer's Name ,.
Designer's Name
Address
Address & 36jV' / S At 's nd
Telephone#
Telephone# 1,3 d !//
Type of Building r"5t!de, tip) Lot Size sq. ft.
Dwelling - No. of Bedrooms %f"� /!X� Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow g Design flow provided 336_ gpd
Plan: Date a %is Number of sheets Revision Date
Title
Description of Soil(s) Pe rr1
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS .J ,,A U All..�__d __-_hX n,-14' p, a'
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 pli a has been issued by the Board of Health.
Signed Date 2 G
Inspections 4—AZ i L, -54 r�K
No.
COMMONWEALTH LTH ®E MASSACHUSETTS
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
FEE
Description of.Work: _�dn"dividual Component(s) 0 Complete System
The un�djersiiggned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( }
by: P� i �l CP G 4A C L.n I&Xp-LA
at _!� L 1rr� 3 �sdc �� j�d,
has been installed in accordance with the provisio s of^310 CMR 15.00 (Title 5) and the approved design plans/as-built plans r
application No. JG1 c�� dated Approved Design Flow (gpd)
Installer A ll'i JFi1"' ---- ' N I N
g to
g C F Inspector: s n' f': d
Desi ner; r .� Date: �
The issuance of this permit shall not be construed as a guarantee that they system will function as designed.
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No. L �� FEE C'S
COMMONWEALTH Of MASSACHUSETTS
Board of Health,/%1� , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system
at _11 4J--, Slf w &/" toru t. as described in the application for
IF
Disposal System Construction Permit No. IG - ai , dated a r
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
i n
Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, Ma Date 14- /� Board of Health L
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