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No: 6 � P� 1 �• FEE'
rOKI
E, vA��plication for a
��1,lfoard of Health, `t'ea r rn Oe4k MA_
AP PLICATION .FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT !/(
Permit to Construct( ) Repair(✓rUpgrrade( ) Abandon( ) ❑ Complete System O Individual Components:
Location ,C 5 PoL
Owner's Name , Ch C1 0,_ r"
Map/Parcel# to - ZO
Address or4h nn
Lot# �5
Telephone# _
Installer's Namei {3 `LXC0.l,Gt•� 1 O
Designer', NameJo0ua^ ea G
AddressAddress
1�1 TcaScrs L QMS
'c 93`� a 61 arm0&6 r4
Telephone# pg 4401 06S.3
Telephone# Sog.G y I
Type.of BuildingLot Size sq. ft..
Dwelling -No. of Bedrooms Garbage grinder ( )
Other- - Type of Building No. of persons Showers ( ), Cafeteria (
Other Fixtures
Design Flow (min. required)g y O gpd Calculated design flow Design flow providedq�1.._ $� gpd
Plan:Date A.Pr o 1 `?HiQ Number of sheets _ Z Revision Date
Title
Description of Soil(s)'.
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS n Box - Z i I•i -(% I
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 in operation until a Certificate of Compliance has been issued by the Board of Ifealth.
Signed. '4j lDate -S-1, ^� q
Inspections. l J v``J �. �"� -� 0 f '�
No.� ':FEE.: �• V�1
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Z-drl rrnn- �;^} .�, , MA. . B
b / fs7
���++ CERTIFICATE OF COMPLIANCE,
Description.of Work; Lrindividual
Component(s) ❑Complete System �^ Cyd
The undersigned hereby certify that the Sewage Disposal System; Constructed (--<,Repaired (wQ, Upgraded ( Abandoned ( ).
by: 4; on
at 4 n r --i k D•c O n; S Q --
has been installed'n accox-oda e with the provisions of 310 CMR 15.00 (Title 5) and the;approved=•design plans/as-built plans relating to
application, No. ` dated �. Approved Design Flow (gpd) %
Installer ^, //
Designer:. I� 0V-\ Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
off'_..- 7 COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM[ CONSTRUCTION PETIT
FEE .pJ , 0
Permission is hereby granted to: Construct( ) Repair( ,Upgrade Abandon( ) an individual sewage disposal systein
at .. '9 _ rJor i k r n : PnL as described in the application for
Disposal System Construction Permit No. ° dated47 9--,-J.
All local conditions must be met.
Provided: Construction. shall be completed wthin.l�ta�the date of this. p.
Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA Date 5 Board of Health