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�✓%% Board of Health, L/i�/1�IO lij, MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - P160-m-plete System ❑ Individual Components
Location
Owner's Name (�
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Map/Parcel#
AddressCIO %2
Lot#
Telephone#
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Installer's Name Co
Designer's Name
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Address9� �
Address P. (') �
Telephone# 0Telephone#
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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. re e8 �Ir >0 gpd Calculated design flow Design flow provided gpd
Plan: Date'/1 i 9-0'JNumber of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS J e kp), L 0)-P
Date of Evaluation
The undersigned afire to ' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to pla the t rake
i until a Certificate of Compliance has been issued by the Board of Health.
Signed i<g%� ✓ Date 4, �0--�
Inspections[- d /� f rL. V.�'�% 44-04
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COMMONWEALTH Of MASSACH6§ETTS -2 0
Board of Health,Aemn Ow MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual .Component(s) Complete System
The undersigned hereby certify that the Selvage Disposal System; Constructed ( ), Repaired ( ),Upgraded andoned ( )
by:, �{j l,�—t�=��,�
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has been installed in accord re witli the provisi�s oy 0 CMei5.00 (Title 5) and the p roved design plans/as-built plans relating to
application No. �r�"' , dated �i S / Approved Design Flow � gpd)
Installer If t_s�
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Designer: fir- e Sn/j S #:4 C Inspector: -/ V/ � . Date: ' 4 2 :4;e
The issuance of this permit shall not be construed as a guar/,e that the system will function as designed.
No. %} , c (-7 -31-1 S 2- �i C t � i:� �Z CS S � FEE � - Q( )
COMMONWEALTH Of MASSACHUSETTS
1-to4 - e -UO! Q
Board of Health, Y4rM6,2n4 MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(.. -abandon( ) an individual sewage disposal system
at S �� + i_c -+ ! - r, c /' - as described in the application for
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Disposal System Construction Permit No. > ated
Provided: Construction shall be completed within tie A'riate of this permit local conctitigM must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co.Charlestown, MA ` Date -d oard of ealth
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