App-Permit-ComplianceNo. �C^ r7-4043> —40 43> C� / P/ �� / FEE S
Board of Health, YN?A�APOTA , MA.
LU APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
t Ar. plication for a Permit to Construct( ) Repair( ) Upgrad Abandon( - ❑ Complete System »idividual Components
ocation
Owner's Name
ap/Parcel#
Address `7
Lot#
Telephone#
r2 ..S/
Installer's Name G✓
Designer's Name
f
Address ,.�71
Address
Telephone# w
Telephone#
Type of Building `5
Dwelling - No. of Bedrooms _
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Lot Size-- sq. ft.
Garbage grinder( }
No. of persons Showers( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
E40
The undersigned agrees to install the v scribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to ace m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No.
Description of Work:
The undersigned her
by: _ C"
at
has been installed i
application No.
Installer )
COMMONWEALT14 OF MASSACHUSETTS'
Board of Health,
CERTIFICATE Of COMPLIANCE
I Component(s) ❑ Complete System
cert�'fyy that the Sewage Disposal System; Constructed ,(,Repaired ( ), UA-e
graded (I). , Abandoned O �
5�._./ o ri ✓i ! �',� i e°�l a C 1 v ��x" '� ' "�f� Ci
with the ovl' i e I0jCMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated Approved Design Flow ') (gpd)
Designer: -Dou, N tr",1 PIE L-N)GT ! , Inspector: i s a Date:
The issuance of this permit shall not be construed as a guava Aee�th tato the system will function as designed.
'DQ PFEE J.
'COMMONWEALTH OF MASSACHUSETTS Ck. 4-
Board (f Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby g�apted to; Construct( Repair( ) Upgrade( ) Abandon ( ) an individual sewage disposal system
at /,7,- as described in the application for
Disposal System Construction Permit No. , dated
!�
Provided: Construction shall be completed within rs of the. date of this permi ..All locVcoitions mustbe met •_�llA Form 1255' Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date ' / Board of Health.� ;Y