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App-Permit-Compliance
No. f0 7 —/7 r c/V7 FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, �'A(Z-MOITM , MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT :/ Application for a Permit to Construct( ) Repair pgrade( ) Abandon() - 0 Complete System Id'Individual Components LocationOwner's Name „fry Map/Parcel# ' , Address Lot# Telephone# 7C1-- 9 14j— L _Installer's Installer'sName kcl� G Designer's Name .r Address 4, Address Telephone# _ 776 • y` Telephone# — 3r- -- Type of Building K. -s, Lot Size Cd!y sq. ft. Dwelling - No. of Bedrooms 7— h 4 c/ 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 Oy 4 1 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 T��T // a 0 rLl L ee rt t, C �c � S' t, anal A Cwt d;0 �u'�v/vti /�nl� ! >n �-C S ��GI ra:5 Le_ O1 to 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 of omp 'ance/has been issued by the Board of Health. Signed �/7 l'�%/' Date 3 Okla Inspections "©� 2 R S�dZS TdY No. '�� !" Q Z'�` � AS FEE :1'�•y O 1) COMMONWEALTH OF MASSACHUSETTS Board of Health, �YAg-MUVTi 4 , MA. CERTIFICATE Of COMPLIANCE LPaG� Description of Work: *Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded -<)_,_Abandoned ( ) by: Fmi k6c' LQncf C'OnSfiC� at /8 Ri olae le Zoos e has been installed in /accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 0, dated �.2 Approved Design Flow (gpd) Installer Designer: U40 cap, Inspector: � Date: P, The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No./ FEE COMMONWEALTH OF MASSACHUSETTS Board of Health,?—MO Vn , MA. - DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(\,)- —Upgrade( ) Abandon( ) an individual sewage disposal system at / {' >, ai.:. 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 peVmit. All local conditions must be met. ate Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA D' -' Board of Health `� 1