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COMMONWEALTH Of MASSACHUSETTS dL#V-74 C
U&Ir �
'S" bard of Health, ` , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeL/ Abandon( ) - LlComplete System I•et ndividual Components
LocationOwner's
Name
Map/Parcel#SO
Address
Lot#
Telephone#
Installer's Name r
Designer's Name
f
Address y
Address /1
Telephone#
Telephone#
_ — 2,
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size� ��(�� c�� sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures l
Design Flow (min), required) HD gpd Calculated design flow Y qV Design flow provide'i L14 gpd
Plan: Date 21 cab l 15 Number of sheets I Revision Date at lag i Is
Title
Description ofSoil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
OF REPAIRS OR ALTERATIONS
H , to -
of Evaluation
../
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 pliance has been issued by the Board of Health.
Signed Date 6 3 fit—
Inspections
7 _2
lq ^' 1 OV FEE oU
No. COMMONWEALTH Of MASSAC14USETTS ���/�
Board of Health, Y � , MA.::
CERTIFICATE Of COMPLIANCE � � � 'tee'1,7
Description of Work: ` U/Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (t Abandoned (
by:at V 4 (' Q� 0.i A An AA 0 ti
has been installed in acVo
application No.
Installer � „ 01
with the rovisions of 310 CMR 15.00 (Title 5) and th a proved design plans/as-built plans relating to
dated 12 Design Flow,(gpd)
Inspector:
Date: 7-.> Sr—,
The issuance of this permit sliall not be construed as a guaraA ee that the system will function as designed.
No. ,6� ��030)C-A�"A��'� ��, 01 �C,Jy`�1`i_ �� �1�i� FEE ()
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Ymd, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(/ Repair( ) Upgrade(/ Abandon( ) an individual sewage disposal system
at 6 0aRAAMfXAf,, as described in the application for
®� Disposal System Construction Permit No. dated r ,
Provided: Construction shall be completed within tlkr the date of this permit. AI local conditions
must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA Date 7 A Board of Health