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! 7 COMMONWEALTH OF MASSACHUSETTS 4i�a.,► +
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L i '� Board o Iealth, 131-0
Y 0 t�i4 , MA.
1KATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair{) /Upgrade O Ahandou- EJ Complete System $i individual Components
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Location 1
Owner's Name Lit _ _�<\. w
Map/Parcel#
14 3
C G.
Address C123�-
Lot#
Telephone# GJ6a_ )��
Installer's Name
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Designer's' Name
Address 94
5 15 k
�/ �2 Or-�
IAddress ?0 BOX _ Y1
Telephone#
_ 77 4--
O L.�.
Telephone#' Gyps — 3 — 13
Type of Building QFI' 16fL / CJT1r1M'Gy-C-1 !d Lot Size sq, ft.
Dwelling- No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafeteria { ).
Other Fixtures
Design Flow (min.
Plan: Date
Title
Description of Sbii(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR
l3} Calculated design flow 40-0 Design flow provided I (A5 gpd
Number of sheets i 01tv Revision Date
Name of Soil Evaluator
Date of Evaluation
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 lace the system in operation until a Certificat f CompI' Lncee s` b en issued by the Board of Health.
Signed Date
Inspections
No.r � � E
COMMONWEALTH OF MASSACHUSETTS f
iiw l3 BoardofHenith, ../%1C'1 ,MA.
CE T011CATE Of COMPLIANCE
Description of Work:, Q Individual Component(s) O Co plete System
The undersigned hereby certify that the Sewage Disposal Sstem Constructed ( ), Repaired ( ), Upgraded), Abandoned O`
by
at
has been installed in accordan e with the provisions of 0 CMR 15.00 (Title 5) and the
application No. _ dated. - � . Approvedbesign Flow -Z4
Installer eac,,, ; L � , Y , , L, V
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Designer: � Vv��ornl�lii,c s Inspector:
design plans/as-built plans relating to
Date:
The issuance of this permit; shall not be .construed as aguaraomee that the system will function as designed.
No.��..-{'7, -1085 rte:( .)�-�.e FEE v
/7COMMONWEALTH OF MASSACHUSETTS
Board of Health, y affi0i] 11�- , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is.herebygranted to; Construct( ) Repair( ) Upgrade (s<-) Abandon( ) an individual sewage disposal system
at C'� as described in the application for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed within of he date of this nit. All local conditions must be. met.
Form 1255 Rev. 5/96 A.M. SWkin Co. Charlestown, MA Date �/ -7Board of Health