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No. 700(
/P- '-)47
COMMONWEALTH OF MASSACHUSE Ts
Board of Health, 'hl WRO QT7+ , MA
FEE' Lam"
330
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade ZAbandon ( ) a/complete System 0 Individual Components
Location
.G.G
�,
Owner's Name
Map/Parcel#�
Q crJ
Address
�),® v /\
Lot#
Telephone#_
Installer's Name
Designer's Name
Address%i;z,,
`C
Address
� C
Telephone#
72
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size S= c c5 .
Garbage grinder {
Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) d gpd Calculated design flow Design flow provided 3 gpd
Plan: Date \Q C ti' `� Number of sheets Revision Date
Title
Description ofSoil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator Z , �� N c.SJ Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 place the system ' operation until a Certificate of Complianc has been issued by the Board of Health.
Signed Date �® C.5`
No. FEE .`CQCOMMONWEALTH OF MASSACHUSETTS
Board of Health, YA,910 01)4 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s), U'domplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (, ), Upgraded (/Abandoned(
at
has been installed)'-1 accordance with the provisions of 3 CMR 15.00 t 0 (Title 5) and he p roved design plans/as-built plans relating to
application No. j V - 7, dated %C� �/da7�Approved Design Flow (gpd)
Designer: Inspector: '
m�rr� &- e4d Date: !1 X
p guarantee system on as designed.
The issuance of this permit shall not be as a ar7antee*that(t�he s temwill function
1L_ af.)—, F FEE r X
Board of Healt& yA1ZM0 Q+ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (, <Abandon ( ) an individual, sewage disposal system
at ? :`� Lam. !,.. L �. x" 6 as described in. the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within t��f the date of this perm' All local co ditions must be met.
Form1255 Rev.5/96 A.M. Sulkin Co. Charlestown, MA Date iBoard of Health ." `-� �`•"�`