App-Permit-ComplianceNo. 111D C' 4 8-60 5-6, 0 LD V Ic-, -+7 _`C 0 V .%52--1 FEE'
AT � LVIVE'I®N W kALIH kA MAZOMAIUT3EI V)
Board of Health, MA. l
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ❑ Complete System 215�lvidual Components
Location la
W ffi-t� U-1)Q1
Owner's Name � S 4
Map/Parcel#
4� y,
Address
Lot#
Telephone#
Installer's Name
Designer's Name "Q .'r
Address (��
o�� ��
Address ��O 98j �Z•�e+.� W� �. a
Telephone#
- 26-A (j'j\�
Telephone# 5-big. 3Ud _ S b\\,
Type of Building l L st&Q1A1- CA Lot Size O-Q, R2 sq. ft.
Dwelling- No. of Bedrooms 3 Garbage grinder { )
Other Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) 3'� b gpd Calculated design flow •2 Design flow provided Sq( - 2 S gpd
Plan: Date Ls I a01 t% Number of sheets z Revision Date ti
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1 P-u,,) �d 17- &x , La —2e
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agmea to not to place the system in operation until a Certificate of Cpnipfiahce has been issued by the Board of Health.
Sign e�`t rS Date % %—
Inspections
nn .pp-
No. C FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, lY} Cl t/ MA.
CERTIFICATE OF COMPLIANCE
` a
Description of Work: f-i'`ndividual Component(s), ❑ Complete System •e"
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded A"'
Abandoned (, }
has been installed in accordance with the provisions of 3 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application, No. � 4 , dated �-" % ,; Approved Design Flow °� g )
Installer (z1 `'2l�'n N t�F /i �x�. -
Designer: M ; i1k IL -f SUti S Inspector: %� ^ f i;rt,2o✓ !r" Date: .e
The issuance of this permit shall not be construed as a guarant that the system will function as designed.
- - - n
No. % I 1) C -A 0— — 00 S5- 6 (VI FEE � • �t!
- K COMMONWEALTH OF MASSACHUSETTS Gv /ozszo
Board of Health, MA.
Permission is hereby
at } h'
DISPOSAL SYSTEM CONSTRUCTION PERMIT
te-d to; Construct( ) Repair(
Upgrade (Abandon ( } an; individual sewage disposal system
as described in. the application for
Disposal System Construction Permit No. , dated !
Provided: Construction shall be completed within 1,4m the date of this per nit; All local condi 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Dater ( Board of Health