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No, g�tr-6� 1t)q-� -
4-1 r jb �D FEE YdV
COMMONWEALTH OF MASSACHUSETTS 4-49 7aS
Board of Health, YPI 9 MI f 5 QN , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( -Implete System ❑ Individual Components
Location
Owner's Name
Map/Parcel# lv v
�
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address
f 1.
Address
Telephone#
_ �`
Telephone# -
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder( )
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow' Design flow provided 35V gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) -eAZe
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION
t
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a s to not to place the system in oper ' n until a Certificate of Co pIi has been issued by the Board of Health.
Signed Date
• r ,�-- �—— t-,c� : mac.. ".
Inspections.
is
No. t)c FEE O�
r ��Ni[ Nl ,$ 11.11®F MASSACHUSETTS
Board of Health, YA
JjM 0 UTH MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) 8 complete Systerhi x
The undersigned hereby certify that the Sewage Disposal S stem; Constructed( ), Repaired ( ), UpgradedAbandoned ( )
by: r S�
at _ ,�
has been installed in ccord c . with the rovisi s of 0 CMR .15;00 (Tit16 5) athe roved design plans/as-built plans relating to
application No. dated Approved Design Flow'�(gpd)
Installer
Designer: _ l Inspector: Date: .%
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.��,�� ^o{Cf� Ir ���-�"t FEE
IS Ck*17B3
BoarcL (f Health, �/, yQ _ MA. -�
DISPOSAL S1TSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at °' )1 L'! .,� "" .1� i � ( .�i ^ `�;zr�i ✓ as described in the application for
Disposal System Construction Permit No a dated
Provided: Construction shall be completed within tlrrt rs of the date of this rmit. All local cmd1tions must be met.
Form '1255 Rev. @/96 A.M. Sulkin Co. Charlestown, MA Date' !!,d of Health
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