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No. , t�,P� 6—N1o7
F,LD-rP--«- 00-703 3
COMMONWEALTH Of MASSAC14USETTS
Board of Health, _)�&WQL)Th , MA.
FEE Y' V
-#12,0oo
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (eupgrade ( ) Abandon( ) - Complete System 0 Individual Components
Location S-1
Owner's Name
Map/Parcel# 33 1,131
f
Addressio0, &xj— r / S
Lot#
Telephone#
Installer's Name �U1 .t
Designer's Name
Address j �u��sl(�,
Address/37 cL% O 'ti
Telephone# y �Ff . $ �(�
Telephone# ��j 2
Type of Building Lot Size Al ?`5-0 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow Design flow provided 333 gpd
Plait: Date
�MC a o2/ D % Co Number of sheetsC _ Revisiot Date
Title J[Ju'/�i'/i%�i�Jli
Description of Soil (s) '
Soil Evaluator Form No.
OF
Name of Soil Evaluator
Date of Evaluation
/ ; 0 //
The undersigned agrees to iriiiidl t ie above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not'to;plac a tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed -' DateCe
Inspections
No ice_ FEE a r i1
COMMONWEALTH OF MASSACHUSETTS.
Board of Health, - ya-&101-1 1111M,
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) ,Q'Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired::( ), Upgraded ( ), Abandoned ( )
by:
at
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. dated "' Approved Design Flow _F (gpd)
Installer
Designer: :, Inspector:a t� 'i Date:
.._ ! 1"
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. a' ,' ,.. - s • FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, \6 .M0( Znj , MA..
71,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(,.-.,,) Upgrade( ) Abandon( ) an individual sewage disposal system
at 4:;
Disposal System Construction Permit No ` 'r r'' , dated
as described in the application for
Provided: Construction shall be completed within t4aree yeaxs of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date �' cj' Board of Health
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