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COMMONWEALTH Of MASS C14USETTS
Board of Health, ) , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERM IT
Application for a Permit to Construct( ) RepairwUpgrade( ) Abandon( ) - ❑ Complete System gindividualComponents
Location 3 q
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� Owner's Name
Map/Parcel#
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Address 3 (05
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Lot#
Telephone# k o,3 —P
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Installer's Name
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Designer's Name
Address 2-y
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Address
Telephone#
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Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( }
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Va l"4- - /44 L f ✓1� 11 a � � I�1L Yy 19
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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 tolace,, the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed X.�. XY //gdh1qj aOUf &, Date
Inspections
Board of Healthh, n k� p �T , MA.
FIFIDTIrl ATnF C®l��PI TANCIF
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Description of Work: 'Individual Component(s) ❑ Complete System Add
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Gf ,�The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (V(UpgrAbandon ( )
by: KLPW
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has been installed in
application No.
Installer �I-A
with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated ® Approved Design Flow (gpd)
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Designer: - Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
-9 e97- is CCE. ,
COMMONWFALTH Of MASSACHUSET TIS
Board of Health, �Ja MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ('V1 Upgrade
Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. /9 d� , dated/
Provided: Construction shall be completed within three years of the date of this pertit.. ,A.#1 local condition must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA Date f Board of Health f�