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COMMONWEALTH OF MASSACHUSETTS
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Board of Flealth, T �d , MA.
APPLICATION FOR DISPOSALy5O TEM C?Complete
STRUCTION PERMIT
plication fora Permit to Construct( ) Repair( ) Upgrade( Abandon - System ❑ Individual Components
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Location 5 �,
7.. / jJ
YC— Owner's Name t
Map/Parcel#3Y
X �
Address _ 5 %ilJ
Lot#
Telephone# -
Installer's Name
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/ n , Designer's ,Nam :24,, -13Z&S,�-
Address �'
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Address e-5 "
Telephone#
Telephone#
Type of Building Lot Size.I sq. ft
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min, required) J gpd Calculated design flow 11.7 Design flow provided gPd
Plan: Date �a�� t/ //� Number of sheets S Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS /Ile— ! • /�GO ns?/CGn
t2/!lt'G n
The undersigned ees to inst th above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire to of to place a tem in operation until Certificate of Compliatice has been issued by the Board of Health.
Signed Date AL /!'
Inspections
No. 'i FEE: 4s co
COMMONWEALTH Of MASSAC TT 1�05—�S-D
Board of Health, afw o 1 , MA f b It ✓
CERTIFICATE OF COMPLIANCE o %4 0419
Description of Work: 0 Individual Component(s) Wtomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded l Abandoned O'
by:.rt+�I
at
has been installed
'n accordance with the provisions of 3l Q CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No r _> dated ;ifs( 'Approved Design Flow �gpd) f
Installer
Designer:>0 Inspector: !k "� ° .! i Date: r''^�. �,• ~- ,�'
The issuance of this permit shall not be construed as a,guaraoe f at the system will function as designed.
No. �r 1�-' "" t 10 5z+` t .r'i�i'L iJ + ' FEE
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COMMONWEALTH Of MASSACHUSETTSd60-
Board of Flea{.t{a, dElk
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DISPOSAL SYSTEM CONSTRUCTION- PERMIT
Permission is hereby granted to; Construct(,,,) Repair( ) Upgrades( � Abandon( ) anindi.-,=idualsewage disposal system
at SS -2 /1'46e-- j as described in the application for
!�'�
Disposal .System Construction Permit No. ; dated 1).c��
Provided: (construction shall be completed within tla.r-s ebate of this pe,, All local conditions must be ;met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date � `7 J, Board of Health
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