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No. -&4k Dc— 19-2,q 7 7 FEE ��Uv
COMMONWEALTH OF MASSACHUSETTS 314b
Board of Health,MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
f . ppl cation for a Permit to Construct( )`Repair( ) Upgrad�andouO - •Complete System O Individual Components
Loatiorr 0 r.I -ilrr,
Owner's Name � Arai 6/A- �
M• /Parcel# Q
Address 7 I /ro Jvll,.
Telephone# �Lot# �G•tvol
Installer's Name /Fj j(C/` L, etn d �G:1 1��'r`
Designer's Name K- O�k
Address p10 rak ? Yll rl )%VI OC
Address G A
Telephone# Je;,. 77417, 'Y�a
Telephone# SO?l 77S 9706
Type of Building n r, "'k, 4, Lot Size i' o sq. ft.
Dwelling - No. of Bedrooms �Gv/• Garbage grinder(
Other - Type of Building No. of persons Showers ( ), Cafeteria-( ).
Other Fixtures U
Design Flow (min, r quired) gpd Calculated design flow! Design flow provided /� gpd
Plan: Date G 6& GLS. Number of sheets /l Revision Date
Title ))
Description of Soil (s) � ,Sly /Ccs
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S t� / / �J,/r+� / .>OC/ Tz i J o I _ . K -
A, - /�'/. IL 7-1 AJ
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 ta vlace the system in operation until a Certificate of Co pli ce has been issued by the Board of Health.
Signed Date /G G/
i
No.� "'. �— �� % FEE
COMMONWEALTH OFMASSACHUSETTS �
Board ofHealth, , MA•
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(sl �'-D Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ),Upgraded �i(, Abandoned ( )
by /E iKat. 4,a , C -,^ S
/ /01v G
at
has been installed in accordance with the provisions of NO CMR 15,00 (Title 5) and thea proved design plans/as-built plans relating to
application No. _ �, dated Approved Design. Flow (gpd)
Installer i7rl�tf^ G
Designer: le f �7 �r/, I C Inspector: R' Date: _ -i " fi
The issuance of this permit shall not be construed as a guava 11 that the system will function as designed.
No. 6cli-I QC--{ C4—.
COMMONWEALTH Of MASSACHUSETTS
Board of Health,/i , MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
FEE -—(J
Permission is hereby granted to Construct( p) Repair( ) Upgra)� Abandon( } an individual sewage disposal system
at 70 6%&Z ,/Ilr, r"-S�Xrc41 as described in. the application for
Disposal System Construction Permit No., dated 2. --Z .`
Provided: Construction shall be completed within t"ar�the date of this permit. 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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