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COMMONWEALT14 OF MASSACHUSETTS C 373 8
Board of Health,� { MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - ❑ Complete System DofnQividual Components
Location L(p
Ccok-(^v-\ i v y
Owner's Name 1 C
Map/Parcel#-7'7
Address
Lot#
Telephone#
Installer's Name
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Designer's Name
Address � ` z)
Q f� i ll ��
Address
Telephone#
b �q
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building 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 Soil (s) _
Soil Evaluator Form No.
OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate off Compliance has been issued by the Board of Health.
Signed ! Date 2L l t I-)
Inspections
No. C � C 7 - ��1 e(� FEE . 00
COMMONWEALTH OF MASSAC14USETTS 4
Board of Health, Yaw 0 �r� , MA.
CERTIFICATE Of COMPLIANCE
Description of Work; Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ),Repaired 0, Upgraded( ), Abandoned ( )
by: c c7--, �A r_-1� rx ,'y - - - - -- at C l
has been installe in acco jdance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ,L— dated Approved Design Flow ---' (gpd)
Installer
Designer: Inspector: "::V (& fwF �I �� Date: Z'-"` 0
The issuance of this permit shall not be construed as a guar ,, that the system will function as designed.
No. F1C)k4 ), - ~fi '?may scc"Tr t-4 FEE C
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �) QW O I MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( 4 Upgrade{ ) Abandon(ln individual sewage disposal system
at [, r As.c as described in the application for
Disposal System Construction Permit No.dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co, Charlestown, MA Date °'" /rr Board of Health