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7 COMMONWEALTH OF MASSACHUSETTS CW76-6
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Board of Health, )nieOy-nl ,MA.
PP LICATI0N R DISPOSAL S YSTIM STRUCTION P MT w
Application for a Permit to Construe Repair()Upgrade()Abandon() - Comp to S tem ❑ Tn vidual Co nents ry
Location
Owner's Name >
Map/Parcel#
Address
Lot#
Telephone# 117 v
.e _ lrCl
Installer's Name
esigner's Name.
Address
Address -3il &4L4 C
Telephone# _
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required) / y gpd Calculated design flow 7/
Plan: Date Number of sheets
Title
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided % % ,� gpd
Revision Date
Description of Soil (s) .� 4�2�
Soil Evaluator Form No. i' Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a es to not to place the system in operation ntil a Certificate off Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. EC- -DC (0-0150 Ci ` ' f FEE � /10, UQ
COMMONWEALTH OF MASSACHUS TTS;'
Board of Health,
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ./ `I`mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at 9 �^
has been installed/tn accor a e with the rovisions of 10 CMR 15.00 (Title% and t approved design plans/as-built plans relating to
application No. 7 dated -0 '/�. A proved Design Flow., (gpd)
Installer 4—
Designer: CS l- . A,44 Inspector: Date: /
60
The issuance of this permit shall not be construed as a gu tee Aat the system will function as designed.
-y ^
No. .V)(- i�j-00 131,1 -.+ + mA-1'4.'r FEE
SET TIS
Board ofHealth, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) , Abandon( ) an individual sewage disposal system
f
at rr r ` �°�► as described in the application for
Disposal System Construction Permit No. !�' 7 dated%
Provided: Construction shall be completed within Lli 7 t e date of this permit local conditions must be met.
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Form 1255' Rev, 5/96 A.M. Sulkin Co. Charlestown, MA Date ,`' Board of Health 1�