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No. b o C -f9 7-7.3
COMMONWEALTH Of MASSACHUSETTS
FEE t b 4 Ob
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Board of Health, �ko,,Yiu MA.
APPLICATION FOR DISPOSAL SYS- 'l. NSTR11JCTI'Ur1V PERMIT
Application for Permit to Construct( ) Repair�►UpgradeO ando� Complete System ❑ Individual Components
Location [ 4
Map/Parcel#s'
ddress oY'✓tom ,
Lot#
Telephone#
_ 3 Yb
Installer's Nameji�i re,— Z � L ��
Designer's Na
S L rc (� iv+r a
Address P C! G � S.
Address ) 6
'L � S'9' i,
Telephone# O _ 6 -6y(
eo
Tele
a S (,0
Type of Building E.
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures % /
Design Flow (min. r uir d) 33b gpd Calcu
Plait: Date l Number of sheets
Title
I C`
Desct'Ntion o Sb* 4L Sf< f(�
Soil ENo. Name ofSN,
DESCRIPTION OF REPAIRS OR ALTERATIONS ns'7
-t . je,- ik,-, kvs' 1 /
Lot Size 10 sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
;n flow f J C/ Design flow provided J'`S gpd
Revision Date
Date of Evaluation
'e c,/
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to plac the s in operation until a Certificate of Co plian has been issued by the Board of Health.
Signed Date oZ u� 1/; -�h;
Inspections
No. FEE L00
C®l�I�[®N 1LT14 OF MASSACHUSETTS 7 tq
Board of Health, YW-KQQ-n4 , MA.
CERTIFICATE Of COMPLIANCE
Description of Work:ividual Component(s) ❑ Complete System
The undersigned herebycertifythat the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
at Ii/6__Fre,
�OO_�s_ has
n-—
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and e approved design plans/as-built plans relating to
application No. dated Approved Design Flow ® (gpd)
Installer -)Z, ked=
Designer: I b!ee 6W+K&g4 rrn Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. -__._..,.C, LD -1 17
�3.,,__.....................,��.,��y'`-�FEE
Eon
lOMMO1EALT14 OF MASSACHUSETTS G�-�* 5-7 (_M
Permission is hereby
at
Board c f Health, )Ajgjm:o uni , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
to; Construct( ) RepaiA,-)— Upgrade( ) Abandon( ) an individual sewage disposal system
Disposal System Construction Permit No. , dated
as described in the application for
Provided: Construction shall be completed within three years of 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