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No. 130i -DC --(G—01 1' FEE SSe 00
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Board of Health, �L UV a , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) UpgradejjYAbandon( ) - E7Complete System ❑ Individual Components
Location
911 VA& AV/Ia kHA
Owner's Name �jfi it 6vlid ao o
Map/Parcel#
(0 �' (j�
Address aS � 5Wdj &flq 1 \46AOK
Lot#
Telephone#
Installer's Name e�� y Q �(,Vt
Designer's Name Root -e-
Address 3o
0,( 2l OA 0_G1
Address 4OI re5� F� J� arf fl.l tli.�t-(n
Telephone#
O(
Telephone# -1 4 -- s
Type of Building 0�
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required) 2./�V gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil (s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
_ Lot Size � sq. ft.
Garbage grinder ( )
No. of persons Showers( ), CafeteeAa ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree o not to pla the system in operation until a Certificate of Co pli ce has been issued by the Board of Health.
Signed CDate
a
Inspections
r
No. _13CAC - 1 o —61'i + /'S." FEE S5 5. 00
COMMONWEALTH OF MASSACHE sfj
Board of Health, YARMOV14 MA. 0
CERTIFIC TE Of COMPLIANCE
CE oat°
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedV,Abandoned
G�( )
by: t ';�1 r ra �_ y , �� �i �° c C (�A;t 1 ll�'
at I, ( ( I, -
has been installed in accor n with the rovisions of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
applicat %l No./� dated` r . Approved Design Flow (gpd)
Installerate . -Tk4
Designer: LNkU!',E t�(AY' l -°t .. ! Inspector: ' Date: '" z
The issuance of this permit sh not bE construed as a gua ee at the system will function as designed.
No. ►s � . � �+ "� � � 1 C � i I . 'i' (Z C.} �'I� N FEE 5. O 0
Board (f Health, )ft tM:1c , MA..
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission its hereby granted to; Construct( ) Repair( ) UpgradeV1 Abandon( ) an individual sewage disposal system
at 0/ f/_ as described in the application for
Disposal System Construction Permit NOI dated d "� ' r
Provided: Construction shall be completed withi s d to of this per 't. All
local con�pons must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Health