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C® jI,TII OF M ASSACHUSETTS TK -
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Board of Health, 'Mm. ���✓�% �� �'�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(eUpgrade( ) Abandon( ) - Ll Complete System Andividual Components
Location 4? e C �.f'�� %�
Owner's Name /,0-..6?�/f•�
Map/Parcel# V/
Address
Lot#
Telephone# S`C>
Installer's Name�>--,W L' �p�d'Y✓J'r
Designer's Name•��r� fy,►,��1'/f�' e
Address 6- X07' -1A -'�oG!` y �7,�
Address �_,.�'vy�,d�ifG ,%p>f
Telephone# 64-�-
Telephone#
Type of Building C�
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size sq. ft.
Garbage grinder ( )
No. of persons 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 of Soils) tS'Gs;
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t n to place tem in operation until a Certificate o Compliance has been issued by the Board of Health.
Signed Date
� Inspections
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No.FEE
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COMMONWEALTH LTH OF MASSACHUSETTS ck4qn 1 i
Board of Health, �n-M4 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 4fon vidual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired AZupgraded ( ), Abandoned ( )
by: G77 -0s,) J-„,-'�4” 6..r' 4-00c
at 4=7�G"r��`,i'a�,�'` .�i�.�,�y .�+e+ kmw„ow aw,11,10
has been installed in accordancy with the provisiojis, of 31Q CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to 71
application No. dated a -Tokpproved Design Flow (gpd)
Installer OJ
Designer: d -16' J'.��Aw .1° -Inspector: ( Date: �!
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. ::'� i (m, eoF `-a -nc J V �. FEE
COMMON LT14 OF MASSACHUSETTS q0 1-7
Board of Health,MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(Ar."Oupgrade( ) Abandon( ) an individual sewage disposal system
C�-'`/at .0c: as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within tbie- f tgAate of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown. MA Date ” Board of Health /