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COMMONWEALTH OF MASSACHUSETTS &-jtns�3
Board of Health, YA-2M0 0-n4 11,11M.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location J.l
Owner's Name S"VDD
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name
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Designer's Name
Address
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Address
Telephone#
aC� a r_(\NXS
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
1 Evjluator Date of Evaluation
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 tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date Z fo t C
Inspections
No., -:q COMMONWEALTH Of MASSACHUSETTS FEE �
Board of Health, , MA. �-' " o
CERTIFICATE Of COMPLIANCE
Description of Work: 4Yndividual Component(s) ❑ Complete System �I
--The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Rep€ied ( ), Upgraded �),Abandoned ( )
by: Jc z\, 3 ,_1,
at
� W UU
has been insta?ed in acc rdance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 1 dated 4 . Approved Design Flow (gpd)
(( ►►
Installer
i L i
Designer: Inspector: -1 ti ���,; .i
J
The issuance of 's permit shall not be construed as a guarantee that the system
Date: ,
will function as designed. t1
No. 1�G�'1 1 %V SC �1 - T K—t FEE 16
�j COMMONWEALTH Of MASSACHUSETTS 055
Board of Health, = r , , MA.
DISPOSAL SYSTEM[ CONSTRUCTION- PERMIT
Permission is herebyranted to;Construct(+2 ELOGA
g ) ) Upgrade ( ) Abandon�an indhidual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No:_. dated -
Provided: Construction shall be completed within three Oto be date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date !��) %* Board of Health �//�� i Y�