App-Permit-CompliancefV
No. VVDC, bL D i 1--t9 - b 607D (0 � &. �� /"���r �� ��%F-� FEE . 60
7 — COMMONWEALTH Of MASSACHUSETTS Ck43621
FOR
of Health, tJ`T Y i , MA.
APPLICATIONFO DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair ()U pgradeO Abandon( - ❑ Complete System -Individual Components
Location 3� flet�evl Pv_<_
Owner's Name
Map/Parcel# aL
Address
Lot# 7o
Telephone#
Installer's Name jZ; K« ZAA A (''�A54 Id,CJ\
Designer's Name
Address f6 &x 'Ve, sc,� � .J�1-.
J��
Address „) G3 C7' Rei
Telephone# X061-771," G %
1Telephone# Sa 0 _?W G l�U
Type of Building 5
Dwelling No. of Bedrooms
Other -Type of Building
No. of persons
Lot Size i )t s -V —sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (mi . re aired)3 gpd Calculated desi n flow 3s Design flow provided gpd
Plan: Date 7 j H Di Number of sheets Revision Date
Title
Description of Sbil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ^ 1� �� • b CSC 4
The undersigned a ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t oto place a ntil a Certificate of Com ance has been issued by the Board of Health.
Signed Date -a li1
Inspections &0__
COMMONWEALTH Of MASSACHUS
Board of Health, VA&tA00T," _114A. �/ e l t^
Ole
CERTIFICATE OF COMPLIANCE � f—) -P —/7
Description of Work: tIndividual Component(s) ❑;Complete System's
The undersigned hereby certify that the Sewage Disposal System; Constr,(uctedV, RepairtaUpgraded ( ), Abandoned
at 3,3)
•��
has been installed in accord
nce with the
application No.dated '
Installer 14. M iCti`~ /;0A1
'ovisi s of=Q CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
Approved Design Flow - 0 (d)
A
Designer: e }.S'e.-- Inspector: jaw Date:
The issuance of this permit shall not be construed as a guar a that the system will function as designed.
No.
CALL)( (7-010-Z— FEE -'t. 06
COMMONWEALTH OF MASSACHUSETTS
Board ofHeealth, \ &QJAA e),L i ;A �,MA.
DISPOSAL SrSTE CONSTRUCTIOT PERMIT
Permission is hereby granted to; Construct( ) Repair j Upgrade( ) Abandon( ) an individual sewage disposal system
at 3-� as described iii the application for
Disposal System Construction Permit No. -L%7 "�, dated'
Provided: Construction shall be completed within thjr- o iFie date of this per i X11 local coi. ittons must be met.
Form 1255 Rev, 5/96 A.M.Sulkin Co. Charlestown, MA Date —% Board of Health