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COMMONWEALTH Of MASSACHUSETTS
Board of Health, �/:� i%% , MA. �A
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT O P7
Application for a Permit to Construct( ) Repair( ) Upgrad Abandon( - ❑ Complete System'Individual Components
Location 3-- 6S
NI ..Clj- 1&)d WSW -
wner's Name c;jc h1l
Map/Parcel#
Address i a) , ff
Lot#
0,-
Telephone# 6-10cj 4'//
Installer's Name a I' Ys
6 r 017--d Ca,,,�
Designer's Name el ,0,
Address �3 � &�
��
Address (31,C aS� �JO- 1A-011
Telephone# S Cd2
Telephone# a'�+�. -7 7,f— 5 2
r
Type of Building
Dwelling No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min, require) gpd Calculated design flow ff—Design flow provided �65-2�gPd
Plait: Date ag1'1 Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
C/
ame of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
12- -7-�,7 0 v (a�c� u 1�' AeeA---1Z'
The undersigned agre to uastall a o descri ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to td p ce system ' o e tion until a Certificate of Compliance has been issued by the Board of Health.
Signed Date `/T/ 2
FEE�>, C /—"� 00 0
S QC) J
Board of Health, _Yki m a ylll , MA.;,
t t' 11-20 tl0
CTIFI[CATE Off' �'®MPLIANC � ;
Description of Work: &Qlno'dividual Component(s) ❑ Complete System
K.�
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (.>), Xbandoned O .....
by: a -� 3 G'b T rS Cc,,i S±
at ? ` /- en CW,
has been installed i co�a-*with th61pL-oY'isions7f 10 CMR 15.00 ( itle 5) and the approved design plans/as-built plans relating to
application No. �, dated Approved Design -Flow (gpd)
Installer
Designer: j; on -4- -4— !t 3 _ Inspector. �X�'Ll� �`1C �!� Date: � �-^ /��/
The issuance of this permit shall not be construed as a gua tee that the system will function as designed.
No. `n J •- `n" c'T Ct3 1> �5 FEE t,52;. QQ
7—/
COMMONWEALTH ®F NIASSACIIUSETTS �, u. M. o.
Board of Health, yA9&&Mj MA.
DISPOSAL SYSTEM][ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade+-< Abandon ( ) an individual sewage disposal system
at(05 �a vat . ,o �" n -) 'P S /n T.tis t.1 �T as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within.tla� s o date of this p mi . All local condi' ns must be met.
i
Form 1255Rev: 5/96 A.fM. Sulkin Co. Charlestown, Ma, /Date B
' ' 0 oa`r�d of Healthf �;Zj