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Board of Health, Y&MOOT71„ MA.
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APPLICATION FORDISPOSAL SYSTEM CONSTRUCTION EINif 2 202
Zppli ation O for Permit to Construct( ) Repair( ) Upgrade Abandon - U Complete System ❑ I • TH DEPT.
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ation3_7
Owner's Name
Ma
/Parcel* clot— 1(4
Address
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Lol
tt
Telephone#
Installer's
Name
Designer's; Name
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Address —7-75
ress
Telephone# Ct
Telephone#
Type of Building �)WV tZ J e
Dwelling No. of Bedrooms_
Other -Type of Building
Other Fixtures
Design Flow (min, required)
Plan: Date 1 _ ltj l `d)nj
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of,Soil Evaluator
No. of persons
Lot Size CS _ sq. ft.
Garbage grinder ( )
Showers ( ) 'Cafeteria
Design flow provided' _ _ gpd
Revision Date
Date of Evaluation
The undersi a t the v des • ed Individual Sewage; Disposal System in accordance with the provisions of TITLE 5 and
further afire s o e in o 'on until a Certificate of Compli'an a has been issued by the Board of Health.
Signed - ' Date 0
Inspections
t
No. &I WX —1 l _022RJ6 �� FEE J
' COMMONWEALT14 OF MASSAC €€USETTS
Board of Health, " Aew2t—, MA. 0
r CERTIFICATE OF COMPLIANCE
Description of Work: `PIndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constr ucted ( ), Repaired ( ),Upgraded (Vf, Abandoned
by:'lr' fi
has been installed i ac orda e with the rovist s of 10 CMR 15.(? r(Title 5) and tl e approved design plans/as-built plans relating to
application No. � �' � dated U r ApprovedDesign Flow (gpd)
Installer ."O k_ J (1,) 1 V)0 ,. WC. -
Designer: fl" $ l r3 ss ector: .te f.I'4W Date: eiZ 7—
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. f
No. 7 i, c - S —M24o F- a FEE � 00
COMMONWEALTH Of MASSAC USETTS
Board of Health, _AIM®1 TM—, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) epair( ) Upgrade( Abandon( ) anindividual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within hr o tide date of Zth*mit. All local conditi C41S must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date. f � /aard of Health