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COMIMONWEALTH OF MASSAC14USETTS
.
Board of H%Mbealth, y u"J-4 APR04 2018
APPLICATION FOR DISPOSAL SYSTEM[ CONST T
Application fora Permit to Construct( ) Repairx Upgrade( ) Abandon( ) 0 Complete System XIndividual Components
LocationL—
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Owner's Name
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Map/Parcel#
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Address 4P E
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Lot#
Telephone#
Installer's Name ��
Designer's Name
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Address (S3
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Address
Telephone#
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Telephone#
Type of Building RE?,� Q 1;FK—r Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Nurnber of sheets Revision Date
Title
Description ofSbil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS H-10 -D — I�OYC w i rt -t` C-os�,
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 to pnae syst m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. d �� "� i�rci L FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.C�-��•
CERTIFICATE OF COMPLIANCE 4
Description of Work: XIndividual Component(s) 0 Complete System
The' undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (A' Upgraded ( ),Abandoned ( )
by: QAfZW 10 e JI-= `$'���r"t�
at ?,(o C_t cia-
has been installed i .,ac rdance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.4fl, dated' fa—[. Approved Design Flow (gpd)
Installer Z t G� E�
Designer: JA Inspector: -�.1� b..�% Date: moi'
The issuance of this permit shall not be construed as a guarantee that the,system will function as designed.
CIA
-- COMMONWEALTH OF MASSACHUSETTS
Board of Health,� � D Unt , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE' J.:a .. 00
44 0% 1
Permission is hereby granted to; Construct( ) Repair(X) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at as described in. the application for
Disposal System Construction Permit No, ,dated
Provided: Construction shall be completed within three years of the date of this poftnt All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Go. Charlestown; MA Da Board of Health -� /