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No.
s I Tn-17 Oo�v'Rd�oE S5�00
COMMONWEALTH LTH Of MASSAC14USETTS c- 7830
Board of Health, Y,gd &TIA- , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT
pplication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ❑ Complete System C3Individual Components
.
11ILocat*on kb Q� k ' C6 . 0.
Owner's Name VNnLk,L�
Map/Parcel# 048, (
Address \}
Lot#
Telephone#2ko_ Astj
Installer's Narn
Designer's Name L-�T . T -
AddressD-a. �`C (� S
�5 Address f, r- � _ vv Zgxf met
Telephone# . \
Telephone#
Type of Building`
Dwelling - No. of Bedrooms
Other - Type of Building _0
No. of persons
Lot Size
sq. ft.
— Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixturese�
Design Flow (min. required) �JJ�JQ gpd Calculated design flow J .6n Design flow provided gpd
Plan: Date! \� Number of sheets , Revision Date
Titlegcoc) bb C-. QAC,.(.) C e- Scak M -,s c\(UJ{ ` d `( rok) 5.. CAefyo
Description of Soil(s) �' `:��Vl `,`f�re� , SC!`C�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DRSCRiPTION OF REPAIRS OR AITF.RATIONS rw V 3 �C, ti, o CSM 1;-CC1t',C� k -q"&
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
„further agrees of to lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Ins ections 2 % —
11 G
R
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COMMONWEALT14 OF MASSACHUSETTS E 155, f � � 7 � 0
�' � Beard o Health, , MA. � � -
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (Y, Abandoned ( )
by:(-.. \)
at Qr e_jc� rcyn,-
has been installed in accordance with the provisionsof 310 CMR 15.00 (Title 5) and the
/japppved design plans/as-built plans relating to
application No. dated ".�� R! Approved Design Flow %9�c`gPd)
Installer Cn en
Designer: C��,� .rte ce �. fi 1 f (�ile.�� l` e_ Inspector: Date:
The issuance of this permit shall not be construed as a guaramate that the system will function as designed.
No.4
COMMONWEALTH OF MASSACHUSETTS 44�7630
Board of Health, Y�Q•lYliiLT1a- , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) UpgradeK) Abandon( } an individual sewage disposal system
at i° �c f + �� �Lr 0 . C .`` >>- t �GeC ��!�.,-1 as described in the application for
Disposal System Construction Permit No../..,date
�dy� �-
Provided: Construction shall be completed within � s othe date of this permit. All local conditions must be met.
g Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date
J�� -t /Board of Health C>�M,