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17A—
No.
FEE
h'�iCOMMONWEALTH OF MASSACHUSETTS � J
YP.FMCUTH HEALTH DEFT. rr,
Board of Health, i146 ReUTE 28, MA. O% -el S
APPLICATION FOR DISPO N'fflM'M9 UCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade,(olfAbandon( ) - ❑ Complete Systenwdl�dividual Components
Location I
rJ5, t—
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name t vS �� �'esJ?rcy,
Designer's Name
��G-._..
Address
23 n H,- a"� M
Address 3
Telephone#
'3 & a-
Telephone#
Type of Building L.otSize sq. ft.
Dwelling - No. of BedroomsS✓` ,rii 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 (P 193 GJ Number of sheets / Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
r 1)
The undersigned grees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree ri top ce ' ' peration until a Certificate o Compliance has been issued by the Board of Health.
Signed
Inspections
No.
Description of Work:
The undersigned 1
by:
at 11
COMMONWEALTH Of MASSACHUSETTS
FEE�L/D
Gd /�/ -`J�50 3
Board of Health, I Ir- r•
C R,
ERTIFIC E Of COMPLIANCE
�� /
'EJ individual Components) ❑ Complete System (3 � 1
by cer�ti�fy/ that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded�Abandone )
kv) -e r
has been installed in accordance with the provisions cif 10 CMR 15.00 (Wtle 5) and the approved design plans/as-built plans relating to
application Nc. C' dated — Approved Design Flow _(gPd)
Installer
Designer: i ce— rc, o / 'rim, F -r, . Inspector:/J %W �°� Date:
The issuance of this perqut shall not be construed as a guarantee that the system will function as designed.
No. / //Sf FEEy _ —
COMMONWEALTH Of MASSAC14 SETTS
Board of Health, A./e, T t---\ e , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 7,iS--P/- L�r-�. �.r. ::. ') �G i > as described in the application for
Disposal System Construction Permit No. `��° �dated 7'Z
Provided: Construction shall be completed within tlizaeycarot the date of this errnit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date ? Board of Health
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