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j No. f/ VWdJ C- /4-61 � 1 FEE U O W
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! Board of Health, -1p(L-mLm+ , NL4•
F
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
pp cation for Permit to Construct( ) Repair(/Upgrade( ) Abandon( - ❑ Complete System O Individual Components
Al
L cation
Owner's Name Qyvan
Map/Parcel# - ��/
Address L Avf-
Lot#
Telephone# LL, -5 ?.- 16 9
Installer's Name
Designer's Name
Address vZ i r
Address
Telephone# Zjp -
Telephone#
Type of Building R e'41 L61-1 P I Lot Size
Dwelling - No. of Bedrooms -25
Other - Type of Building No. of persons
sq. ft.
_ Garbage grinder ( )
Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
The undersigned agr es o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furthgrees to to lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signe Date ._
Inspections
F
U
No. -77 4..a a (/ FEE
COMMONWEALTH Of MASSACHUSETTS � K3 C4 00 7y(-, ct .
Board of Health, "! Aim C)lT'% , MA.
CERTIFICATE Of COMPLIANCE + 19,&K
Description of Work: Ml Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired V, Upgraded ( ), Abandoned ( }
by: aur
at A -Y vAdd-
,has
d-
,has been installed 'n acco ce with the piovisiqns of 3 0 CMR 15.00 (Title 5) and th}e approved design plans/as-built plans relating to
application No. dated . - Approved Design Flow (gpd)
Installer -(' 60,A G5-Tb-pW OBJ
r,,
Designer: � Inspector: C%,l.K.� Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, 2 -Nib J� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Ck* 007 4G�
Permission is hereby granted to; Construct( ) Repair Upgrade ( ) Abandon( ) an individual sewage disposal system
at %)Tjcr—e-r Ave- as described in the application for
Disposal System Construction Permit No. r/6 _.4/ , dated 9
Provided: Construction shall be completed withiwears of the &te of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date -/- Board of Health