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COMMONWEALTH Of MASS CHU ETTS
Board of Fleallh, ���� , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrad �Aba.doii( - ,Z'Complete System ❑ Individual Components
Location q
G LE V 6LAT4i) WAY
Owner's Name A�L KP_0 %f y
Map/Parcel#
3(o/-73
Address /P 111a2f D04 S:01
Lot#
Telephone# 4�e - YeO - 7609
Installer's Name C.C. GONI STR.UGT a� lNC •
Designer'sName pkRREj M M. M ryCXS R.S.
Address is
blAWAS {A'Tj SOUiN PEAN►S 02.660
Address 'f3 yt,46 sTREE-T D11XBdl=•, M$. D2332-
Telephone#
50$ . 3% la11
Telephone# 7 Of) , 50-57,02f 3
Type of Building keslpcma Lot Size 12, 50,0 sq. ft.
Dwelling - No. of Bedrooms 4' Garbage grinder
Other -Type of Building j1LA No. of persons Showers ( ), Cafeterias
Other Fixtures
Design Flow (min. required) $50 gpd Calculated design flow �b� • 8 Design flow provided gpd
Plan: Date 19 7-y, 70lD Number of sheets Re-%Rsion Date W 14
Title 517-E f SEWAiff'PUtrJ
Description ofSoil (s) Loosy/neolvn! z?,Vz E s4wb
Soil Evaluator Form No. W%h Name of Soil Evaluator b. sf4WX Date of Evaluation 1/2.3 /200 3
DESCRIPTION OF REPAIRS OR ALTERATIONS /N5rAGL AtEW Id'0y GM.LON 5EPric rSMtu Wr1W I FVaA.
S D 0 4k L 4PJ LEA GH e-NMM BE,C5
r
The undersigned ees t install the ab n ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t of t a to operation until a Certificate of Com liance has been issued by the Board of Health.
Signed Date
Inspectionsy
Z
.� ®MM®I � IC $^ C" -7l5 P) `"1
'or ASS CHUS�ETTS o� �EEE
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Board of Health, ` �1Q lid' , MA.
.
CERTIFICATE� Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 6-0mplete-$ystem
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded (, Abandoned ( )
atti
has been installed s' 1 a cord ce with the rovisions of 0 CMR 15.00 (Title 5) and r ed design plans/as-built plans relating to
application No.
Approved Desi n Flow
Installer cvn 1 —rtP 0-02-
Designer: V .Idc"�'Ic�-� Inspector: � Date:i',e
The issuance of this permit shall not be construed as a guar4 ee that the system will function as designed.
No:fhi� ���. �GRi�(��l'j FEE•,®tJ
COMMONWEALTH Of MASSACHUSETTS - -7/ 9.7
Board of Healtli, NA&M O QT* MA..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;, Construct( ) Repair( ) Upgrade Abandon( ) an indiNridualsewage disposal system
at
Disposal System Construction Permit No.
Provided: Construction shall be complet
Form 1255 Rev. 5/96 A.M.;Sulkin Co. Charlestown, MA Datc
as described in. the application for